Provider Demographics
NPI:1184790503
Name:HERNANDEZ, EUSEBIO GUILLERMO (MD)
Entity type:Individual
Prefix:
First Name:EUSEBIO
Middle Name:GUILLERMO
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 1:5635 W FORT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209-3154
Mailing Address - Country:US
Mailing Address - Phone:313-849-3920
Mailing Address - Fax:313-849-0824
Practice Address - Street 1:5635 W FORT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-3154
Practice Address - Country:US
Practice Address - Phone:313-849-3920
Practice Address - Fax:313-849-0824
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69827-202084P0800X
MI43011106682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001942000Medicaid
FL25427TMedicare PIN