Provider Demographics
NPI:1104860030
Name:HERNANDEZ, JESUS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:
Last Name:HERNANDEZ
Suffix:JR
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 1:2000 GREEN RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1598
Mailing Address - Country:US
Mailing Address - Phone:734-995-3764
Mailing Address - Fax:
Practice Address - Street 1:104 W 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1409
Practice Address - Country:US
Practice Address - Phone:989-386-9951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI048887207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJH048887OtherBLUE SHIELD
MI104081910Medicaid
MI102865106Medicaid
MIM60660026Medicare PIN
A78934Medicare UPIN