Provider Demographics
NPI:1336366863
Name:HERNANDEZ, GEORGE R (IDC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5733 LILAC LN APT 207
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-6872
Mailing Address - Country:US
Mailing Address - Phone:760-855-6614
Mailing Address - Fax:
Practice Address - Street 1:5733 LILAC LN APT 207
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6872
Practice Address - Country:US
Practice Address - Phone:760-855-6614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman