Provider Demographics
NPI:1548553753
Name:HERNANDEZ, ROBERTO DANIEL
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:DANIEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15705 MIAMI LAKEWAY N APT 219
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2197
Mailing Address - Country:US
Mailing Address - Phone:786-985-7423
Mailing Address - Fax:
Practice Address - Street 1:489 HIALEAH DR
Practice Address - Street 2:SUITE 10
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-5320
Practice Address - Country:US
Practice Address - Phone:786-953-6302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002538600Medicaid