MEDICARE: MANUEL H HERNANDEZ M D P A

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	207ND0101X	MOHS-Micrographic Surgery Physician	0076069	FL
2	207ND0900X	Dermatopathology Physician	0076069	FL
3	207NP0225X	Pediatric Dermatology Physician	0076069	FL
4	207NS0135X	Procedural Dermatology Physician	0076069	FL
5	207N00000X	Dermatology Physician	0076069	FL

General Provider Information

NPI Number	:	1316064231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANUEL H HERNANDEZ M D P A

Provider Business Mailing Address
First Line	:	4235 KINGS HWY UNIT 101
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33980-8421
Country	:	US
Telephone Number	:	941-764-7773
Fax Number	:	941-764-7681

Provider Business Practice Location Address
First Line	:	4235 KINGS HWY
Second Line	:	SUITE 101
City	:	PUNTA GORDA
State	:	FL
Zip	:	33980-8415
Country	:	US
Telephone Number	:	941-764-7773
Fax Number	:	941-764-7681

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MANUEL HERNANDEZ
Credential	:	M.D.
Telephone Number	:	941-764-7773

Provider Enumeration Date	:	03/24/2007
Last Update Date	:	10/06/2023

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