Provider Demographics
NPI:1023007739
Name:HERNANDEZ, WILSON LEON (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:LEON
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:12606 GREENVILLE AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1921
Practice Address - Country:US
Practice Address - Phone:214-691-9377
Practice Address - Fax:214-853-9415
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK32322085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00473193OtherRRMCR PROVIDER
TX8AE57OtherBCBS PROVIDER ID
TX042232104Medicaid
TX8AE57OtherBCBS PROVIDER ID
TXG49801Medicare UPIN