Healthcare Provider Details

I. General information

NPI: 1275629412
Provider Name (Legal Business Name): VICTORIA L HERNANDEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 W POLK ST SUITE G1
CHICAGO IL
60605-2000
US

IV. Provider business mailing address

2525 S MICHIGAN AVE ATT: MEDICAL STAFF OFFICE
CHICAGO IL
60616-2315
US

V. Phone/Fax

Practice location:
  • Phone: 312-922-3011
  • Fax: 312-922-5860
Mailing address:
  • Phone: 312-567-7924
  • Fax: 312-567-6189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036066374
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: