Basic Information
| Provider Information | |||||||||
| NPI: | 1740253483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERRER | ||||||||
| FirstName: | FERNANDO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 247 ROUTE 100 | ||||||||
| Address2: | SUITE 1002 | ||||||||
| City: | SOMERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105893231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149628290 | ||||||||
| FaxNumber: | 9149628851 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 SIMSBURY RD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604090413 | ||||||||
| FaxNumber: | 8604995418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 035121 | CT | N | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 035121 | CT | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 2088P0231X | 286455 | NY | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | 286455 | NY | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 001351212 | 05 | CT | MEDICAID |