Healthcare Provider Details

I. General information

NPI: 1104211275
Provider Name (Legal Business Name): SUSAN FERNANDES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2015
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S GROVE ST STE 105
MARSHALL TX
75670-5295
US

IV. Provider business mailing address

PO BOX 1326
MARSHALL TX
75671-1326
US

V. Phone/Fax

Practice location:
  • Phone: 903-935-9441
  • Fax: 903-938-1246
Mailing address:
  • Phone: 903-927-3782
  • Fax: 903-927-1764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberS2579
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: