=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053678052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDER FERNANDO SAN DIEGO JR. D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2012
-----------------------------------------------------
Last Update Date | 08/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2404 N COURTENAY PKWY
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-452-1327
-----------------------------------------------------
Fax | 321-454-9208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2404 N COURTENAY PKWY
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32953-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-452-1327
-----------------------------------------------------
Fax | 321-454-9208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO3686
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------