Healthcare Provider Details

I. General information

NPI: 1861487720
Provider Name (Legal Business Name): GUILLERMO HERNANDEZ JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE STE. 202
LAS CRUCES NM
88011-8259
US

IV. Provider business mailing address

807 STONE CANYON DR
LAS CRUCES NM
88011-0980
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-8193
  • Fax:
Mailing address:
  • Phone: 505-521-0109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA-701-79
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: