Healthcare Provider Details

I. General information

NPI: 1780208538
Provider Name (Legal Business Name): ANTHONY DAVID HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2020
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

IV. Provider business mailing address

22171 CLOCKTOWER WAY
BOCA RATON FL
33428-4640
US

V. Phone/Fax

Practice location:
  • Phone: 877-832-2652
  • Fax: 800-792-9021
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN31036
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME157748
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: