Healthcare Provider Details

I. General information

NPI: 1336147198
Provider Name (Legal Business Name): JUAN O HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK DR STE 301
OWOSSO MI
48867-1293
US

IV. Provider business mailing address

PO BOX 13008
LANSING MI
48901-3008
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-3613
  • Fax: 517-364-9605
Mailing address:
  • Phone: 517-364-9650
  • Fax: 517-364-9605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301054500
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: