Provider Demographics
NPI:1487049250
Name:FERNANDO, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FERNANDO
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 1:4508 ROYAL LYTHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5689
Mailing Address - Country:US
Mailing Address - Phone:573-355-2429
Mailing Address - Fax:
Practice Address - Street 1:1000 W NIFONG BLVD STE 120
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5615
Practice Address - Country:US
Practice Address - Phone:573-444-6331
Practice Address - Fax:855-576-4137
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018023711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine