=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851454839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIDEL HERNANDO HENRIQUEZ MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 05/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10796 PINES BLVD SUITE 103
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-442-1402
-----------------------------------------------------
Fax | 954-442-1418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10796 PINES BLVD SUITE 103
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-442-1402
-----------------------------------------------------
Fax | 954-442-1418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. FIDEL HERNANDO HENRIQUEZ
-----------------------------------------------------
Credential | MDPA
-----------------------------------------------------
Telephone | 954-442-1402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | ME0058002
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------