Basic Information
| Provider Information | |||||||||
| NPI: | 1932105624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDO | ||||||||
| FirstName: | BENEDICT | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 687 CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065163774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039326481 | ||||||||
| FaxNumber: | 2038894953 | ||||||||
| Practice Location | |||||||||
| Address1: | 687 CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065163774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039326481 | ||||||||
| FaxNumber: | 2038894953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 016636 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110194408 | 01 | CT | RAILROAD MEDICARE | OTHER | 2033800 | 01 | CT | AETNA | OTHER | 001166362 | 05 | CT | MEDICAID | 016636 | 01 | CT | CONNECTICARE | OTHER | P571228 | 01 | CT | OXFORD | OTHER | 010016636CT02 | 01 | CT | ANTHEM BLUE SHIELD | OTHER |