Healthcare Provider Details

I. General information

NPI: 1316064231
Provider Name (Legal Business Name): MANUEL H HERNANDEZ M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 KINGS HWY SUITE 101
PUNTA GORDA FL
33980-8415
US

IV. Provider business mailing address

4235 KINGS HWY UNIT 101
PUNTA GORDA FL
33980-8421
US

V. Phone/Fax

Practice location:
  • Phone: 941-764-7773
  • Fax: 941-764-7681
Mailing address:
  • Phone: 941-764-7773
  • Fax: 941-764-7681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0076069
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number0076069
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number0076069
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number0076069
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number0076069
License Number StateFL

VIII. Authorized Official

Name: MANUEL HERNANDEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 941-764-7773