Provider Demographics
NPI:1710907944
Name:HERNANDEZ, MADELINE (OD)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-4499
Mailing Address - Country:US
Mailing Address - Phone:813-885-3937
Mailing Address - Fax:
Practice Address - Street 1:1510 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5416
Practice Address - Country:US
Practice Address - Phone:813-971-0471
Practice Address - Fax:813-464-2763
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3590152W00000X, 152WC0802X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620915700Medicaid
FLV08452Medicare UPIN