Provider Demographics
NPI:1336147198
Name:HERNANDEZ, JUAN O (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:O
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-9650
Mailing Address - Fax:517-364-9605
Practice Address - Street 1:300 HEALTH PARK DR STE 301
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1293
Practice Address - Country:US
Practice Address - Phone:989-723-3613
Practice Address - Fax:517-364-9605
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301054500207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4456946Medicaid
MIOC36345027Medicare ID - Type Unspecified
MI4456946Medicaid