Provider Demographics
NPI:1174770614
Name:FERNANDEZ, HENRIQUE JOSE (MD)
Entity type:Individual
Prefix:DR
First Name:HENRIQUE
Middle Name:JOSE
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HENRIQUE
Other - Middle Name:JOSE
Other - Last Name:FERNANDEZ ANGULO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5820 GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8256
Mailing Address - Country:US
Mailing Address - Phone:719-576-0263
Mailing Address - Fax:
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2749
Practice Address - Country:US
Practice Address - Phone:719-595-7680
Practice Address - Fax:719-595-7687
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-50732207RG0100X
MT98813207RG0100X
FLTRN11230207RG0100X
CO48454207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO75771055Medicaid