MEDICARE: MRS. DOLORES HERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	369690091	NY

General Provider Information

NPI Number	:	1053747212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DOLORES HERNANDEZ

Provider Business Mailing Address
First Line	:	87 COLUMBIA ST
Second Line	:	APT. 12K
City	:	NEW YORK
State	:	NY
Zip	:	10002-1916
Country	:	US
Telephone Number	:	917-279-2444
Fax Number	:

Provider Business Practice Location Address
First Line	:	87 COLUMBIA ST
Second Line	:	APT. 12K
City	:	NEW YORK
State	:	NY
Zip	:	10002-1953
Country	:	US
Telephone Number	:	917-279-2444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/19/2013

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Directions to “ MRS. DOLORES HERNANDEZ ” Practice Location

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