=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952651382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAJEEV RUBEN FERNANDO MBBS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2012
-----------------------------------------------------
Last Update Date | 01/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 N JEFFERSON ST 2712
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60661-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-876-6115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 PLEASANT ST STE 414
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50309-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-241-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | BP20041756
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | MD-43759
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------