Healthcare Provider Details

I. General information

NPI: 1164674040
Provider Name (Legal Business Name): MARTHA HERNANDEZ-ILLAS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 NW 114TH AVE SUITE 3
DORAL FL
33178-4374
US

IV. Provider business mailing address

4005 NW 114TH AVE SUITE 3
DORAL FL
33178-4374
US

V. Phone/Fax

Practice location:
  • Phone: 305-251-3991
  • Fax: 305-251-7982
Mailing address:
  • Phone: 305-251-3991
  • Fax: 305-251-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberME87694
License Number StateFL

VIII. Authorized Official

Name: MARTHA HERNANDEZ-ILLAS
Title or Position: MEDICAL DOCTOR
Credential:
Phone: 305-251-3991