Provider Demographics
NPI:1205049368
Name:HERNANDEZ, JO CAROLYN (MD)
Entity type:Individual
Prefix:DR
First Name:JO
Middle Name:CAROLYN
Last Name:HERNANDEZ
Suffix:
Gender:F
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:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3395
Mailing Address - Country:US
Mailing Address - Phone:503-215-4323
Mailing Address - Fax:503-215-0297
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-4323
Practice Address - Fax:503-215-0297
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15359207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR118066Medicare ID - Type UnspecifiedPSH MEDICARE #
ORE60606Medicare UPIN
OR118060Medicare ID - Type UnspecifiedPPMC MEDICARE #
OR118062Medicare ID - Type UnspecifiedPSTV MEDICARE #
OR118068Medicare ID - Type UnspecifiedPMH MEDICARE #
OR118064Medicare ID - Type UnspecifiedPNH MEDICARE #