Provider Demographics
NPI:1881679421
Name:HERNANDEZ, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 165154
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33116-5154
Mailing Address - Country:US
Mailing Address - Phone:786-882-1919
Mailing Address - Fax:786-206-3161
Practice Address - Street 1:9619 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-2804
Practice Address - Country:US
Practice Address - Phone:786-882-1919
Practice Address - Fax:786-206-3161
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84218208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00191950OtherRARILROAD MEDICARE
FL268126900Medicaid
FLN220840OtherWELLCARE
FL13085OtherBCBS
FLN220840OtherWELLCARE