Provider Demographics
NPI:1700060092
Name:HERNANDEZ, MARIO AUGUSTO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:AUGUSTO
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 1:18509 STATESVILLE RD STE B1
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-5703
Mailing Address - Country:US
Mailing Address - Phone:704-237-3421
Mailing Address - Fax:
Practice Address - Street 1:18509 STATESVILLE RD STE B1
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5703
Practice Address - Country:US
Practice Address - Phone:704-237-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16949207Q00000X
VA0101244562207Q00000X
NC2010-00567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915310Medicaid
KY7100062480Medicaid
KY7100062480Medicaid
VAMC11793Medicare PIN