Provider Demographics
NPI:1861150773
Name:LUIS F FERNANDEZ MD PA
Entity type:Organization
Organization Name:LUIS F FERNANDEZ MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:F
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:941-661-3434
Mailing Address - Street 1:PO BOX 495477
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-5477
Mailing Address - Country:US
Mailing Address - Phone:941-766-1901
Mailing Address - Fax:941-764-7039
Practice Address - Street 1:2400 HARBOR BLVD STE 5
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5038
Practice Address - Country:US
Practice Address - Phone:941-764-7999
Practice Address - Fax:941-764-7039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10091AOtherMEDICARE
FLME0056435OtherSTATE LICENSE