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General NPI Number Information
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NPI Number | 1952892895
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Entity Type | Individual
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Provider Name | CORY JAMES FERNANDES DO
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Gender | Male
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Dates
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Enumeration Date | 05/26/2018
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Last Update Date | 04/09/2025
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Provider Practice Location Address
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Address Line | 4481 VIKING DR
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City | BOSSIER CITY
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State | LA
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Zip | 71111-7414
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Country | US
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Telephone | 318-626-2593
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Fax | 318-399-7716
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Provider Business Mailing Address
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Address Line | 3307 FAIRFIELD AVE
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City | SHREVEPORT
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State | LA
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Zip | 71104-4103
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Country | US
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Telephone | 818-388-9705
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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 | T4919
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 341893
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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