Provider Demographics
NPI:1912169210
Name:HERNANDEZ, OMAR (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
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 1:4927 LAKE RIDGE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3087
Mailing Address - Country:US
Mailing Address - Phone:972-641-9000
Mailing Address - Fax:972-641-9002
Practice Address - Street 1:4927 LAKE RIDGE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3087
Practice Address - Country:US
Practice Address - Phone:972-641-9000
Practice Address - Fax:972-641-9002
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197044401Medicaid
TX8AD149OtherBCBS
TXP01010982Medicare PIN
TX8L1707Medicare PIN