Healthcare Provider Details

I. General information

NPI: 1669587739
Provider Name (Legal Business Name): EDMUND J FERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 E COMMERCE BLVD
SLINGER WI
53086
US

IV. Provider business mailing address

3003 W GOOD HOPE RD
MILWAUKEE WI
53209-2042
US

V. Phone/Fax

Practice location:
  • Phone: 262-644-2900
  • Fax: 262-644-2980
Mailing address:
  • Phone: 414-352-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: