Basic Information
| Provider Information | |||||||||
| NPI: | 1144597527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | ALLAN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 FELTERS ROAD | ||||||||
| Address2: | BUILDING 8 | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072011200 | ||||||||
| FaxNumber: | 3619024588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2011 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01071217A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 285440 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04527193 | 05 | NY | MEDICAID |