Provider Demographics
NPI:1679635833
Name:HERNANDEZ, RAFAEL C (MD, DO)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:C
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 S CORONA AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-5725
Mailing Address - Country:US
Mailing Address - Phone:516-872-3033
Mailing Address - Fax:516-872-5927
Practice Address - Street 1:15 FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4000
Practice Address - Country:US
Practice Address - Phone:516-872-3033
Practice Address - Fax:516-872-5927
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217496208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH22712Medicare UPIN
NY93L761Medicare ID - Type UnspecifiedMEDICARE PROV