Provider Demographics
NPI:1487619144
Name:FERNANDEZ, MANUAL A (MD)
Entity type:Individual
Prefix:
First Name:MANUAL
Middle Name:A
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863-0387
Mailing Address - Country:US
Mailing Address - Phone:732-826-4177
Mailing Address - Fax:732-607-1160
Practice Address - Street 1:205 MAY ST
Practice Address - Street 2:SUITE 103
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3267
Practice Address - Country:US
Practice Address - Phone:732-661-9075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA35509207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0432903Medicaid
NJ551613AGNMedicare ID - Type Unspecified
F18329Medicare UPIN