Provider Demographics
NPI:1114954856
Name:HERNANDEZ, JOHN MANUEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MANUEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:6134 PACIFIC BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2923
Mailing Address - Country:US
Mailing Address - Phone:323-589-3381
Mailing Address - Fax:323-583-6439
Practice Address - Street 1:6134 PACIFIC BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2923
Practice Address - Country:US
Practice Address - Phone:323-589-3381
Practice Address - Fax:323-583-6439
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7216152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190545OtherSAFEGUARD VISION
CA3235893381OtherVISION SERVICE PLAN
CA903261OtherBLOCK VISION, INC.
CA1535OtherCARE FIRST
CANONEOtherTHREE RIVERS PROVIDER NET
CA165OtherVISION PLAN OF AMERICA
CA3351OtherMEDICAL EYE SERVICES/ECN
CANONEOtherADVANTAGE HEALTH NETWORK
CASD0072160Medicaid
CACA 7216OtherECPA/EYEMED
CANONEOtherSOUTH ATLANTIC MEDICAL GR
CA903261OtherBLOCK VISION, INC.
CANONEOtherTHREE RIVERS PROVIDER NET