Provider Demographics
NPI:1467436501
Name:HERNANDEZ, MAURICIO T (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:T
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 830635
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33283-0635
Mailing Address - Country:US
Mailing Address - Phone:305-220-2121
Mailing Address - Fax:305-220-8787
Practice Address - Street 1:11760 SW 40TH ST
Practice Address - Street 2:SUITE 635
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3582
Practice Address - Country:US
Practice Address - Phone:305-220-2121
Practice Address - Fax:305-220-8787
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53791174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE99447Medicare UPIN
FL12390Medicare ID - Type Unspecified