Healthcare Provider Details

I. General information

NPI: 1952454449
Provider Name (Legal Business Name): DR. MARK D HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK D HERNANDEZ MD

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG, H100, SANTA MARGARITA ROAD
CAMP PENDLETON CA
92055-9151
US

IV. Provider business mailing address

9504 PASEO DE LOS CASTILLOS
SANTEE CA
92071-4185
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-8882
  • Fax: 760-725-1267
Mailing address:
  • Phone: 619-334-6959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number0101056186
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: