Provider Demographics
NPI:1568671774
Name:EDWARD P. & DIANE M. HERNANDEZ
Entity Type:Organization
Organization Name:EDWARD P. & DIANE M. HERNANDEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-961-0432
Mailing Address - Street 1:15330 AMAR RD STE A
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-2001
Mailing Address - Country:US
Mailing Address - Phone:626-961-0432
Mailing Address - Fax:626-333-7741
Practice Address - Street 1:15330 AMAR RD STE A
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2001
Practice Address - Country:US
Practice Address - Phone:626-961-0432
Practice Address - Fax:626-333-7741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08489T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004881Medicaid
CA6392750001Medicare NSC
CAGSD004881Medicaid