Provider Demographics
NPI:1568693034
Name:HERNANDEZ PONS, EDGARDO ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:ANTONIO
Last Name:HERNANDEZ PONS
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-622-5677
Mailing Address - Fax:
Practice Address - Street 1:8085 SPYGLASS HILL RD STE 109
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7984
Practice Address - Country:US
Practice Address - Phone:321-622-5677
Practice Address - Fax:321-622-6506
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-02
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118572207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM5347OtherMEDICARE HF
FLHY475ZOtherMEDICARE