Provider Demographics
NPI:1952302648
Name:HERNANDEZ, RICHARD W (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36021 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1531
Practice Address - Country:US
Practice Address - Phone:727-772-1000
Practice Address - Fax:727-771-0770
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086946501Medicaid
FL20438TMedicare PIN
FL20438WMedicare ID - Type UnspecifiedOAF GROUP K0738
FL086946501Medicaid