Healthcare Provider Details

I. General information

NPI: 1790480465
Provider Name (Legal Business Name): KATHERINE MASSIEL HERNANDEZ MENDEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date: 11/06/2023
Reactivation Date: 12/30/2025

III. Provider practice location address

5851 SAINT AUGUSTINE RD
JACKSONVILLE FL
32207-8015
US

IV. Provider business mailing address

1300 HENDRICKS AVE
JACKSONVILLE FL
32207-8680
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-3964
  • Fax: 904-396-0128
Mailing address:
  • Phone: 856-807-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME83275
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: