Provider Demographics
NPI:1861593352
Name:FERNANDEZ, CARLOS OCTAVIO (RCS)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:OCTAVIO
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:RCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE #470
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1431
Mailing Address - Country:US
Mailing Address - Phone:305-777-0425
Mailing Address - Fax:
Practice Address - Street 1:4000 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE #470
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1431
Practice Address - Country:US
Practice Address - Phone:305-777-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6366246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4642Medicare ID - Type UnspecifiedMEDICAL DIAGNOSTICS