Provider Demographics
NPI:1356360143
Name:HERNANDEZ, DIEGO (MD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
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 67000
Mailing Address - Street 2:DEPT 83901
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0839
Mailing Address - Country:US
Mailing Address - Phone:248-858-6144
Mailing Address - Fax:248-858-6232
Practice Address - Street 1:43700 WOODWARD AVE STE 207
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5061
Practice Address - Country:US
Practice Address - Phone:248-481-2100
Practice Address - Fax:248-359-8750
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063339208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH06424Medicare UPIN