MEDICARE: DR. ALEXANDER FERNANDO SAN DIEGO JR. D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	PO3686	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053678052	OTHER		NPI
2	13574563	OTHER		CAQH

General Provider Information

NPI Number	:	1053678052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXANDER FERNANDO SAN DIEGO JR. D.P.M.

Provider Business Mailing Address
First Line	:	2404 N COURTENAY PKWY
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4191
Country	:	US
Telephone Number	:	321-452-1327
Fax Number	:	321-454-9208

Provider Business Practice Location Address
First Line	:	2404 N COURTENAY PKWY
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4191
Country	:	US
Telephone Number	:	321-452-1327
Fax Number	:	321-454-9208

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2012
Last Update Date	:	08/24/2015

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