Provider Demographics
NPI:1851513089
Name:HERNANDEZ, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TOMMY
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:337 OLD SALEM WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9081
Mailing Address - Country:US
Mailing Address - Phone:706-210-1825
Mailing Address - Fax:
Practice Address - Street 1:215 E 1ST ST STE 326
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3190
Practice Address - Country:US
Practice Address - Phone:815-285-5800
Practice Address - Fax:815-285-5691
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-129768207XX0005X, 207X00000X
GABM6733807-R49207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABM6733807-R49OtherTEMP RESIDENCY TRAINING #
IL036129768Medicaid
IL381220030OtherMEDICARE