Provider Demographics
NPI:1003075730
Name:HERNANDEZ, DIANA CATALINA (OD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:CATALINA
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:CATALINA
Other - Last Name:DE LA TORRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:964 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1460
Mailing Address - Country:US
Mailing Address - Phone:321-339-2211
Mailing Address - Fax:
Practice Address - Street 1:964 S WICKHAM RD STE 1
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1460
Practice Address - Country:US
Practice Address - Phone:321-339-2211
Practice Address - Fax:321-339-1183
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002112152W00000X
FLOPC 4308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001652100Medicaid
FL1901VOtherBCBS
FL1901VOtherBCBS
FL001652100Medicaid