Basic Information
| Provider Information | |||||||||
| NPI: | 1982793303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERNANDEZ-ULLOA | ||||||||
| FirstName: | MARIANO | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 BURNET AVE | ||||||||
| Address2: | 3 SOUTH | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855501 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452671000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135842146 | ||||||||
| FaxNumber: | 5135840431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | 35-04-0051-F | OH | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000013583 | 01 | OH | ANTHEM | OTHER | 64781354 | 05 | KY | MEDICAID | 0377702 | 05 | OH | MEDICAID | 3820017 | 01 | OH | UNITED HEALTHCARE | OTHER | 200038970A | 05 | IN | MEDICAID | 655277 | 01 | OH | AETNA | OTHER |