MEDICARE: DR. GABRIEL HERNANDEZ O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	11887T	CA
2	152W00000X	Optometrist	557	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V105259	OTHER	NV	MEDICARE PTAN

General Provider Information

NPI Number	:	1134103393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GABRIEL HERNANDEZ O.D.

Provider Business Mailing Address
First Line	:	6134 W LAKE MEAD BLVD
Second Line	:	E-8
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2659
Country	:	US
Telephone Number	:	702-631-4144
Fax Number	:	702-631-9094

Provider Business Practice Location Address
First Line	:	6134 W LAKE MEAD BLVD
Second Line	:	E-8
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2659
Country	:	US
Telephone Number	:	702-631-4144
Fax Number	:	702-631-9094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	04/26/2012

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