Provider Demographics
NPI:1942220660
Name:HERNANDEZ, JOSE A (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
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 1:450 S MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:33935-4629
Mailing Address - Country:US
Mailing Address - Phone:863-675-2356
Mailing Address - Fax:863-675-2407
Practice Address - Street 1:450 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LABELLE
Practice Address - State:FL
Practice Address - Zip Code:33935-4629
Practice Address - Country:US
Practice Address - Phone:863-675-2356
Practice Address - Fax:863-675-2407
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008697900Medicaid
FL25351VMedicare PIN
FLF81693Medicare UPIN
FL25351W-EFF 1/19/13Medicare PIN