Provider Demographics
NPI:1629606116
Name:HERNANDEZ, JAVIER ALBERTO
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:ALBERTO
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 NW 89TH ST APT 109
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2366
Mailing Address - Country:US
Mailing Address - Phone:786-445-2024
Mailing Address - Fax:
Practice Address - Street 1:1640 BORO PL
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3612
Practice Address - Country:US
Practice Address - Phone:804-585-6909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH655421722470Medicaid