Healthcare Provider Details

I. General information

NPI: 1972247377
Provider Name (Legal Business Name): SOPHIA HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1759 BROAD PARK CIR S STE 201
MANSFIELD TX
76063-7834
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-2274
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV8277
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: