Provider Demographics
NPI:1417407958
Name:HERNANDEZ, RAFAEL JR
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:
Last Name:HERNANDEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10570 S US HIGHWAY 1
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5606
Mailing Address - Country:US
Mailing Address - Phone:772-828-6992
Mailing Address - Fax:
Practice Address - Street 1:10570 S US HIGHWAY 1
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5606
Practice Address - Country:US
Practice Address - Phone:772-828-6992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83014207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty