MEDICARE: DR. JONATHAN CLAVELL HERNANDEZ MD

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	208800000X	Urology Physician	R4379	TX
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1619230869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN CLAVELL HERNANDEZ MD

Provider Business Mailing Address
First Line	:	1315 ST JOSEPH PKWY STE 1700
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77002-8232
Country	:	US
Telephone Number	:	713-652-5011
Fax Number	:	713-654-4056

Provider Business Practice Location Address
First Line	:	1315 ST JOSEPH PKWY STE 1700
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77002-8232
Country	:	US
Telephone Number	:	713-652-5011
Fax Number	:	713-654-4056

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

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	12/07/2018

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