Provider Demographics
NPI:1720063068
Name:HERNANDEZ, MYRIAM A (MD)
Entity Type:Individual
Prefix:MRS
First Name:MYRIAM
Middle Name:A
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-1268
Mailing Address - Country:US
Mailing Address - Phone:407-518-0078
Mailing Address - Fax:407-518-0094
Practice Address - Street 1:1050 W CARROLL ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-1268
Practice Address - Country:US
Practice Address - Phone:407-518-0078
Practice Address - Fax:407-518-0094
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8198208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1720063068Medicaid