Healthcare Provider Details

I. General information

NPI: 1689417826
Provider Name (Legal Business Name): CARLOS HERNANDEZ PAVON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 08/04/2024
Certification Date: 08/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE FL 2
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

11802 REEDY CREEK DR APT 307
ORLANDO FL
32836-6821
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-2622
  • Fax:
Mailing address:
  • Phone: 407-764-3698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberRES.004849
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: