Provider Demographics
NPI:1568537512
Name:HERNANDEZ, GRACIELA E (MD)
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:E
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACIELA
Other - Middle Name:E
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4320 FIR ST STE 206
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3076
Mailing Address - Country:US
Mailing Address - Phone:219-397-2929
Mailing Address - Fax:219-397-2929
Practice Address - Street 1:4320 FIR ST STE 206
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3076
Practice Address - Country:US
Practice Address - Phone:219-397-2929
Practice Address - Fax:219-397-2929
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029949A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100213510AMedicaid
INM400031074Medicare PIN
IN01029949AOtherPRIMARY TAXONOMY CODE