Basic Information
Provider Information
NPI: 1003008327
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HERNANDEZ
FirstName: PEDRO
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5220 BELFORT RD
Address2: SUITE 130
City: JACKSONVILLE
State: FL
PostalCode: 322566017
CountryCode: US
TelephoneNumber: 9044463451
FaxNumber: 9044463013
Practice Location
Address1: 364 WHITE OAK ST
Address2:  
City: ASHEBORO
State: NC
PostalCode: 272035434
CountryCode: US
TelephoneNumber: 8144438225
FaxNumber: 9044463013
Other Information
ProviderEnumerationDate: 08/10/2007
LastUpdateDate: 06/24/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208600000XTD071045MEY Allopathic & Osteopathic PhysiciansSurgery 

ID Information
IDTypeStateIssuerDescription
TD7104501MEMAINE TEMPORARY LICENSEOTHER
2011-0120501NCMD LICENSEOTHER


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