Provider Demographics
NPI:1073591475
Name:HERNANDEZ, JESUS FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:FERNANDO
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:PO BOX 61773
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1773
Mailing Address - Country:US
Mailing Address - Phone:602-682-6701
Mailing Address - Fax:602-240-6177
Practice Address - Street 1:803 N SALK DR
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-5447
Practice Address - Country:US
Practice Address - Phone:520-836-6682
Practice Address - Fax:520-836-6703
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ632390Medicaid
AZWCSKQOtherSUN HEALTH GRP#
AZ632390Medicaid
AZH53239Medicare UPIN
AZZ112962Medicare PIN