Provider Demographics
NPI:1285423616
Name:HERNANDEZ, GUSTAVO JR
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:HERNANDEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-2211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-2211
Practice Address - Country:US
Practice Address - Phone:323-854-3648
Practice Address - Fax:323-854-3648
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No172V00000XOther Service ProvidersCommunity Health Worker