Provider Demographics
NPI:1659395598
Name:HERNANDEZ, VIRGIL THEODORE (DPM)
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:THEODORE
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22851 MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-4747
Mailing Address - Country:US
Mailing Address - Phone:714-265-5824
Mailing Address - Fax:714-384-3897
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:SUITE #202
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3612
Practice Address - Country:US
Practice Address - Phone:714-265-5824
Practice Address - Fax:714-384-3897
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3884213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0869558OtherTAX ID NUMBER
E3884AMedicare ID - Type Unspecified
CA33-0869558OtherTAX ID NUMBER