Provider Demographics
NPI:1942350236
Name:HERNANDEZ, IVAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
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 1:5711 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3602
Mailing Address - Country:US
Mailing Address - Phone:305-667-1036
Mailing Address - Fax:305-667-4938
Practice Address - Street 1:5711 SOUTH DIXIE HWY
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3694
Practice Address - Country:US
Practice Address - Phone:305-667-1036
Practice Address - Fax:305-667-4938
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL608502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF51600Medicare UPIN
FL18504Medicare ID - Type Unspecified