Provider Demographics
NPI:1356561484
Name:FERNANDEZ, CARLOS GUSTAVO (DO)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:GUSTAVO
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-7999
Mailing Address - Fax:
Practice Address - Street 1:1140 E MICHIGAN AVE STE 400
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1806
Practice Address - Country:US
Practice Address - Phone:517-364-9650
Practice Address - Fax:517-364-9605
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016028207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine