=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962696708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH CENTRAL OPHTHALMOLOGY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2007
-----------------------------------------------------
Last Update Date | 10/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19292 STONE OAK PKWY
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-494-4747
-----------------------------------------------------
Fax | 210-494-4741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19292 STONE OAK PKWY
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-494-4747
-----------------------------------------------------
Fax | 210-494-4741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAYMOND H HERNANDEZ III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 210-494-4747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | J2074
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------