Basic Information
| Provider Information | |||||||||
| NPI: | 1497142848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDES | ||||||||
| FirstName: | STUTI | ||||||||
| MiddleName: | CALLISTA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034943273 | ||||||||
| FaxNumber: | 5034946990 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034943273 | ||||||||
| FaxNumber: | 5034946990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2015 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD186576 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RE0101X | MD186576 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.