Provider Demographics
NPI:1619186848
Name:DRS. EDWARD P. AND DIANE M. HERNANDEZ, O.D.
Entity Type:Organization
Organization Name:DRS. EDWARD P. AND DIANE M. HERNANDEZ, O.D.
Other - Org Name:DRS. EDWARD P. AND DIANE M. HERNANDEZ, O.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MOSSER
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-359-8145
Mailing Address - Street 1:1235 BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2408
Mailing Address - Country:US
Mailing Address - Phone:626-359-8145
Mailing Address - Fax:626-359-4116
Practice Address - Street 1:1235 BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2408
Practice Address - Country:US
Practice Address - Phone:626-359-8145
Practice Address - Fax:626-359-4116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08738T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005310Medicaid
CA7121237Medicare PIN
CAWY4040AMedicare PIN