Provider Demographics
NPI:1750345914
Name:HERNANDEZ, JOSE M (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:M
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:M
Other - Last Name:HERNANDEZ-GRAULAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2085
Mailing Address - Country:US
Mailing Address - Phone:309-692-9898
Mailing Address - Fax:309-692-9055
Practice Address - Street 1:7309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2085
Practice Address - Country:US
Practice Address - Phone:309-692-9898
Practice Address - Fax:309-692-9055
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA61590Medicare UPIN
ILL27677Medicare ID - Type Unspecified