Provider Demographics
NPI:1952831695
Name:HERNANDEZ, JOEL AGADO (OD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:AGADO
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 1:420 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4846
Mailing Address - Country:US
Mailing Address - Phone:208-459-2020
Mailing Address - Fax:208-459-2034
Practice Address - Street 1:1906 FAIRVIEW AVE STE 100
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5433
Practice Address - Country:US
Practice Address - Phone:208-459-2020
Practice Address - Fax:208-459-2034
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100411152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDOD100411OtherOPTOMETRY LICENSE