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General NPI Number Information
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NPI Number | 1760481402
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Entity Type | Individual
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Provider Name | FERNANDO S. ESCOVAR M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/15/2005
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Last Update Date | 04/01/2021
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Provider Practice Location Address
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Address Line | 2120 RIETH BLVD STE C
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City | GOSHEN
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State | IN
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Zip | 46526-5858
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Country | US
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Telephone | 574-875-6911
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Fax | 574-875-1057
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Provider Business Mailing Address
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Address Line | 710 N NILES AVE
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City | SOUTH BEND
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State | IN
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Zip | 46617-1924
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Country | US
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Telephone | 574-647-1610
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01044055A
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License Number State | IN
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