Provider Demographics
NPI:1730250457
Name:HERNANDEZ, MIRTA (DPM)
Entity type:Individual
Prefix:
First Name:MIRTA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14871 SW 39TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4726
Mailing Address - Country:US
Mailing Address - Phone:305-984-3865
Mailing Address - Fax:305-207-1587
Practice Address - Street 1:14871 SW 39TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-4726
Practice Address - Country:US
Practice Address - Phone:305-984-3865
Practice Address - Fax:305-207-1587
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2848213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340317300Medicaid
FLU82769Medicare UPIN
FL65652BMedicare ID - Type Unspecified