Provider Demographics
NPI:1851377063
Name:HERNANDEZ, MODESTO III (DPT)
Entity Type:Individual
Prefix:
First Name:MODESTO
Middle Name:
Last Name:HERNANDEZ
Suffix:III
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1724
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78599-1724
Mailing Address - Country:US
Mailing Address - Phone:956-532-7598
Mailing Address - Fax:
Practice Address - Street 1:1400 N WESTGATE DR STE 203
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-3996
Practice Address - Country:US
Practice Address - Phone:956-565-2929
Practice Address - Fax:956-565-6939
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11594582251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T6944OtherBLUE CROSS BLUE SHIELD