Provider Demographics
NPI:1760633812
Name:CERVANTES FANNING, PEDRO (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:CERVANTES FANNING
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 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:704-295-3476
Practice Address - Street 1:13532 STEELECROFT PARKWAY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7545
Practice Address - Country:US
Practice Address - Phone:704-295-3475
Practice Address - Fax:704-295-3476
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01762207W00000X
IL036129100207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01840923OtherRAILROAD MEDICARE
7151944OtherCIGNA
SCNC2885Medicaid
9973753OtherAETNA
NC19N11OtherBCBSNC
NC19N11OtherBCBSNC