Provider Demographics
NPI:1295881746
Name:HERNANDEZ, PETER ANTHONY (DPM)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:ANTHONY
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 W MAIN STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-968-6300
Mailing Address - Fax:631-968-5886
Practice Address - Street 1:85 W MAIN STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-968-6300
Practice Address - Fax:631-968-5886
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0034761213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00830713Medicaid
NY4364220001OtherDME
T81563Medicare UPIN
NY00830713Medicaid