Provider Demographics
NPI:1982618476
Name:HERNANDEZ, JESUS JR (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:HERNANDEZ
Suffix:JR
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-669-5869
Mailing Address - Fax:401-762-3774
Practice Address - Street 1:4475 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7826
Practice Address - Country:US
Practice Address - Phone:702-669-5869
Practice Address - Fax:401-762-3774
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI107662084N0400X
NV121022084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7009548Medicaid
NV100511099Medicaid
NV1982618476Medicaid
RI7009548Medicaid
NV103182Medicare PIN