Provider Demographics
NPI:1538259742
Name:FERNANDO, SONIA G (MD)
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:G
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14555 LEVAN RD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5083
Mailing Address - Country:US
Mailing Address - Phone:734-542-7190
Mailing Address - Fax:734-542-7192
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:SUITE 312
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-542-7190
Practice Address - Fax:734-542-7192
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISF0472862084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110229OtherPREFERRED CHOICE
MI1308246641OtherBLUE CROSS BLUE SHIELD MI
MI171667Medicaid
MI130002187OtherRAILROAD MEDICARE
MI0634806Medicare ID - Type Unspecified
MIB44005Medicare UPIN