Basic Information
| Provider Information | |||||||||
| NPI: | 1063866234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | ENRIQUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FERNANDEZ | ||||||||
| OtherFirstName: | LUIS | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 511 ELIZABETH AVE | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 072061130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9087689549 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | CARRETERA 2 KM 39.50 | ||||||||
| Address2: | HOSPITAL WILMA N. VAZQUEZ | ||||||||
| City: | VEGA BAJA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878581580 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 19469 | PR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 13786-I | 01 | PR | JUNTA MEDICA DE PR | OTHER |