Healthcare Provider Details

I. General information

NPI: 1659387629
Provider Name (Legal Business Name): ROGELIO M HERNANDEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 COUNTRY CLUB DR SUITE E
MADERA CA
93638-1582
US

IV. Provider business mailing address

1130 COUNTRY CLUB DR SUITE E
MADERA CA
93638-1582
US

V. Phone/Fax

Practice location:
  • Phone: 559-673-3297
  • Fax: 559-673-3298
Mailing address:
  • Phone: 559-673-3297
  • Fax: 559-673-3298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA49249
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA49249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: