Healthcare Provider Details

I. General information

NPI: 1649703794
Provider Name (Legal Business Name): DAVID JONATHAN HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S SCHWARTZ AVE STE 102
FARMINGTON NM
87401-5925
US

IV. Provider business mailing address

407 S SCHWARTZ AVE STE 102
FARMINGTON NM
87401-5925
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6700
  • Fax:
Mailing address:
  • Phone: 505-609-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberML60756781
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2020-0896
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: