Healthcare Provider Details

I. General information

NPI: 1073591475
Provider Name (Legal Business Name): JESUS FERNANDO HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 N SALK DR
CASA GRANDE AZ
85222-5447
US

IV. Provider business mailing address

PO BOX 61773
PHOENIX AZ
85082-1773
US

V. Phone/Fax

Practice location:
  • Phone: 520-836-6682
  • Fax: 520-836-6703
Mailing address:
  • Phone: 602-682-6701
  • Fax: 602-240-6177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number29091
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: