Provider Demographics
NPI:1043217763
Name:HERNANDEZ, TERESA (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1184 OCEAN SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-3763
Mailing Address - Country:US
Mailing Address - Phone:386-481-6102
Mailing Address - Fax:
Practice Address - Street 1:1184 OCEAN SHORE BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-3763
Practice Address - Country:US
Practice Address - Phone:386-481-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01319584OtherRAILROAD
FL1043217763OtherMULTIPLAN
FL8282853OtherCIGNA
FL376654300Medicaid
FL5915650OtherAETNA
FL1043217763OtherTRICARE
FL25831OtherBCBS
FL25831VMedicare PIN