Basic Information
| Provider Information | |||||||||
| NPI: | 1184670333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERNANDEZ MIRO | ||||||||
| FirstName: | ULISES | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1149 SAN MICHELE WAY | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334186704 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1874 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 06/08/2011 | ||||||||
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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 | 207L00000X | ME0076116 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 43618 | 01 | FL | BCBS FLORIDA | OTHER | 254498900 | 05 | FL | MEDICAID | 050088996 | 01 | FL | RR MEDICARE | OTHER |