Provider Demographics
NPI:1477627602
Name:HERNANDEZ, MARK ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTONIO
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:12355 SW 76 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183
Mailing Address - Country:US
Mailing Address - Phone:786-282-8983
Mailing Address - Fax:305-598-6536
Practice Address - Street 1:2387 W 68TH ST
Practice Address - Street 2:SUITE 303
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-6889
Practice Address - Country:US
Practice Address - Phone:954-792-0400
Practice Address - Fax:305-598-6536
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2014-04-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME830142084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268434900Medicaid
FL268434900Medicaid
H64036Medicare UPIN