Healthcare Provider Details

I. General information

NPI: 1316110075
Provider Name (Legal Business Name): WILLIAM DOMINGO HERNANDEZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST BATTALION 4TH MARINES BATTALION AIDE STATION
CAMP PENDLETON CA
92055-5380
US

IV. Provider business mailing address

3137 TAUSSIG ST
SAN DIEGO CA
92124-3648
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-1412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: