MEDICARE: OMAR 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	207Q00000X	Family Medicine Physician	N0091	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8AD149	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1912169210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMAR HERNANDEZ MD

Provider Business Mailing Address
First Line	:	4927 LAKE RIDGE PKWY
Second Line	:	SUITE 100
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3087
Country	:	US
Telephone Number	:	972-641-9000
Fax Number	:	972-641-9002

Provider Business Practice Location Address
First Line	:	4927 LAKE RIDGE PKWY
Second Line	:	SUITE 100
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3087
Country	:	US
Telephone Number	:	972-641-9000
Fax Number	:	972-641-9002

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

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	06/22/2023

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Directions to “ OMAR HERNANDEZ MD” Practice Location

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