Basic Information
Provider Information | |||||||||
NPI: | 1912078510 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HENRY FERNANDEZ-COS, MD, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 419 66TH ST | ||||||||
Address2: |   | ||||||||
City: | WEST NEW YORK | ||||||||
State: | NJ | ||||||||
PostalCode: | 070932401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2018619229 | ||||||||
FaxNumber: | 2018619272 | ||||||||
Practice Location | |||||||||
Address1: | 106 GRAND AVE | ||||||||
Address2: |   | ||||||||
City: | ENGLEWOOD | ||||||||
State: | NJ | ||||||||
PostalCode: | 076313574 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2018169636 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2006 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FERNANDEZ-COS | ||||||||
AuthorizedOfficialFirstName: | HENRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 2018169229 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA04426200 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.