Provider Demographics
NPI:1780650176
Name:HERNANDEZ, JUAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:C
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S. HENNEPIN AVE.
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-288-7711
Mailing Address - Fax:815-285-8922
Practice Address - Street 1:102 S HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-288-7711
Practice Address - Fax:815-285-8922
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112949207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL800200003OtherMEDICARE-KATHERINE SHAW BETHEA HOSPITAL
ILK16904OtherMEDICARE-KSB MEDICAL GROUP
IL036112949Medicaid