Provider Demographics
NPI:1568440428
Name:HERNANDEZ, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
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 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:4801 BECKNER RD
Practice Address - Street 2:LEVEL 2 POD 1 STE 2600
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-0000
Practice Address - Country:US
Practice Address - Phone:505-772-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2021-0914208000000X
WAMD00033054208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8191884OtherDSHS NUMBER