Provider Demographics
NPI:1447365739
Name:SERRA, FERNANDO G (MD)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:G
Last Name:SERRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 OLD CAMP RD
Mailing Address - Street 2:STE 142
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5604
Mailing Address - Country:US
Mailing Address - Phone:352-259-0722
Mailing Address - Fax:352-259-0721
Practice Address - Street 1:910 OLD CAMP RD
Practice Address - Street 2:STE 142
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5604
Practice Address - Country:US
Practice Address - Phone:352-259-0722
Practice Address - Fax:352-259-0721
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76142174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255484400Medicaid
FL43918OtherBCBS PROVIDER #
FL43918AMedicare PIN
FL255484400Medicaid