Provider Demographics
NPI:1851454839
Name:FIDEL HERNANDO HENRIQUEZ MD PA
Entity Type:Organization
Organization Name:FIDEL HERNANDO HENRIQUEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FIDEL
Authorized Official - Middle Name:HERNANDO
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MDPA
Authorized Official - Phone:954-442-1402
Mailing Address - Street 1:10796 PINES BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3919
Mailing Address - Country:US
Mailing Address - Phone:954-442-1402
Mailing Address - Fax:954-442-1418
Practice Address - Street 1:10796 PINES BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3919
Practice Address - Country:US
Practice Address - Phone:954-442-1402
Practice Address - Fax:954-442-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058002207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID NUMBER
FL=========OtherTAX ID NUMBER