Provider Demographics
NPI:1972517464
Name:HERNANDEZ-ILLAS, MARTHA (MD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:HERNANDEZ-ILLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10873 NW 73 TERR
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178
Mailing Address - Country:US
Mailing Address - Phone:305-594-5793
Mailing Address - Fax:
Practice Address - Street 1:5333 N DIXIE HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-229-7030
Practice Address - Fax:954-229-0963
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 87694207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00215148OtherRAILROAD MEDICARE
FL01605OtherBCBS
FL01605OtherBCBS
P00215148OtherRAILROAD MEDICARE