Provider Demographics
NPI:1023013711
Name:HERNANDEZ, MARIDEL AILEEN (DO)
Entity Type:Individual
Prefix:
First Name:MARIDEL
Middle Name:AILEEN
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARIDEL
Other - Middle Name:AILEEN
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:19603 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1655
Mailing Address - Country:US
Mailing Address - Phone:586-445-7900
Mailing Address - Fax:586-445-7940
Practice Address - Street 1:19603 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1655
Practice Address - Country:US
Practice Address - Phone:586-445-7900
Practice Address - Fax:586-445-7940
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012021207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1158213464OtherBCBS OF MI
MI0E02258OtherBCBS PIN
MI4869383Medicaid
MI4869383Medicaid
MI0E02258OtherBCBS PIN