Basic Information
| Provider Information | |||||||||
| NPI: | 1578567103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | JACINTO | ||||||||
| MiddleName: | JOSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 718 TEANECK ROAD | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333000 | ||||||||
| FaxNumber: | 2012276207 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 CEDAR LANE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018337087 | ||||||||
| FaxNumber: | 2018337123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 04/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA02831100 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0297972 | 01 | NJ | GHI PPO # | OTHER | 584E41 | 01 | NJ | EMPIRE BC/BS # | OTHER | 1060081 | 01 | NJ | HORIZON NJ HEALTH # | OTHER | 3080924 | 01 | NJ | AETNA HMO # | OTHER | 4208689 | 01 | NJ | AETNA PPO # | OTHER | BP368 | 01 | NJ | OXFORD PROVIDER # | OTHER | 421565777 | 01 | NJ | TAX IDENTIFICATION # | OTHER | 2K1678 | 01 | NJ | HEALTHNET # | OTHER |