Provider Demographics
NPI:1619179835
Name:GUILLERMO HERNANDEZ, JR. DO
Entity Type:Organization
Organization Name:GUILLERMO HERNANDEZ, JR. DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:DI
Authorized Official - Phone:505-522-8193
Mailing Address - Street 1:4351 E. LOHMAN AVE.
Mailing Address - Street 2:STE 202
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8260
Mailing Address - Country:US
Mailing Address - Phone:505-522-8193
Mailing Address - Fax:505-522-8323
Practice Address - Street 1:4351 E. LOHMAN AVE.
Practice Address - Street 2:STE 202
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8260
Practice Address - Country:US
Practice Address - Phone:505-522-8193
Practice Address - Fax:505-522-8323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-701-79207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty