Provider Demographics
NPI:1447313432
Name:RODOLFO E FERNANDEZ MD PA
Entity type:Organization
Organization Name:RODOLFO E FERNANDEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MHSA
Authorized Official - Phone:410-747-6080
Mailing Address - Street 1:724 MAIDEN CHOICE LN STE 202
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5963
Mailing Address - Country:US
Mailing Address - Phone:410-747-6080
Mailing Address - Fax:410-747-3495
Practice Address - Street 1:724 MAIDEN CHOICE LN STE 202
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5963
Practice Address - Country:US
Practice Address - Phone:410-747-6080
Practice Address - Fax:410-747-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD090788000Medicaid
MDG32011Medicare UPIN