=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801034442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO ALFREDO HERNANDEZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2009
-----------------------------------------------------
Last Update Date | 11/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 E COMMERCIAL BLVD #101
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-351-5838
-----------------------------------------------------
Fax | 954-351-5836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 E COMMERCIAL BLVD #101
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-351-5838
-----------------------------------------------------
Fax | 954-351-5836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME 104912
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME 104912
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------