Provider Demographics
NPI:1932192325
Name:HERNANDEZ, JORGE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 2ND STREET EAST
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1029
Mailing Address - Country:US
Mailing Address - Phone:941-746-4151
Mailing Address - Fax:941-746-4345
Practice Address - Street 1:250 2ND STREET EAST
Practice Address - Street 2:SUITE 3B
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1029
Practice Address - Country:US
Practice Address - Phone:941-746-4151
Practice Address - Fax:941-746-4345
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72848207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL200472730OtherTAX ID
FL251982800Medicaid
FL41619OtherBCBS
FLP00121898OtherMEDICARE RR
FLG52796Medicare UPIN
FL251982800Medicaid