Individual
DR. LACTANCIO FERNANDES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1107 EARL FRYE BLVD STE 3, AMORY, MS 38821-5519
(662) 256-9590
(662) 256-9599
Mailing address
PO BOX 6418, GULFPORT, MS 39506-6418
(228) 229-7776
(601) 984-5658
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
14203
MS
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
Primary
14203
MS
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
14203
MS
207RP1001X
Pulmonary Disease Physician
14203
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01578334
—
MS
01
—
P00821834
RAILROAD MEDICARE
MS
Enumeration date
10/10/2006
Last updated
03/04/2013
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