Provider Demographics
NPI:1639585292
Name:HARP RUIZ, FERNANDO
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:HARP RUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 ALFRED ST APT 605
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-3188
Mailing Address - Country:US
Mailing Address - Phone:857-331-2763
Mailing Address - Fax:
Practice Address - Street 1:4001 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-3038
Practice Address - Country:US
Practice Address - Phone:313-993-1245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2024-09-04
Deactivation Date:2015-02-10
Deactivation Code:
Reactivation Date:2015-04-13
Provider Licenses
StateLicense IDTaxonomies
MI2901602103122300000X, 390200000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist