Provider Demographics
NPI:1003148016
Name:JOSEPH M HERNANDEZ MD PA
Entity Type:Organization
Organization Name:JOSEPH M HERNANDEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:M,D
Authorized Official - Phone:386-754-0600
Mailing Address - Street 1:826 SW MAIN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5742
Mailing Address - Country:US
Mailing Address - Phone:386-754-0600
Mailing Address - Fax:386-755-9737
Practice Address - Street 1:826 SW MAIN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5742
Practice Address - Country:US
Practice Address - Phone:386-754-0600
Practice Address - Fax:386-755-9737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277541700Medicaid