Provider Demographics
NPI:1821168378
Name:HERNANDEZ, JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
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 1:289 SW MACON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340
Mailing Address - Country:US
Mailing Address - Phone:954-261-9747
Mailing Address - Fax:850-973-4726
Practice Address - Street 1:826 SW MAIN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5742
Practice Address - Country:US
Practice Address - Phone:386-754-0600
Practice Address - Fax:386-755-9737
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44356208D00000X, 207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277541700Medicaid
FL94525OtherBCBS
FLME44356OtherFL LICENSE
FL94525GMedicare ID - Type Unspecified
FL277541700Medicaid
FL100108Medicare PIN