Basic Information
| Provider Information | |||||||||
| NPI: | 1205821352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ BLAY | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330243624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549839191 | ||||||||
| FaxNumber: | 9544497651 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330243624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549839191 | ||||||||
| FaxNumber: | 3058291401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME93447 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 274947500 | 05 | FL | MEDICAID |