Basic Information
| Provider Information | |||||||||
| NPI: | 1770699696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDES JUNG | ||||||||
| FirstName: | FLAVIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JUNG | ||||||||
| OtherFirstName: | FLAVIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 238 ARSENAL ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829450 | ||||||||
| FaxNumber: | 3157821330 | ||||||||
| Practice Location | |||||||||
| Address1: | 238 ARSENAL ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829450 | ||||||||
| FaxNumber: | 3157821330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0210X | 2000-01601 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 208000000X | 212699 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4131550 | 05 | MD | MEDICAID |