Healthcare Provider Details

I. General information

NPI: 1669033908
Provider Name (Legal Business Name): ULISSES HERNANDEZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 7TH ST
WASCO CA
93280-1502
US

IV. Provider business mailing address

211 W 49TH ST
LOS ANGELES CA
90037-3203
US

V. Phone/Fax

Practice location:
  • Phone: 866-707-6664
  • Fax:
Mailing address:
  • Phone: 323-384-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPTL1182
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A20036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: