Provider Demographics
NPI:1285603233
Name:HERNANDEZ, JACINTO A (MD)
Entity type:Individual
Prefix:
First Name:JACINTO
Middle Name:A
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6490 MOUNT MORIAH ROAD EXT
Mailing Address - Street 2:STE 200
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-3841
Mailing Address - Country:US
Mailing Address - Phone:901-565-0244
Mailing Address - Fax:901-565-9605
Practice Address - Street 1:6490 MT MORIAH RD EXT
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3729
Practice Address - Country:US
Practice Address - Phone:901-565-0244
Practice Address - Fax:901-565-0616
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14556207RN0300X
ARR3093207RN0300X
TN12320207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208992313Medicaid
TN053526Medicaid
TN4023944OtherBLUE CROSS BLUE SHIELD
1680070005OtherCIGNA
TN3188369Medicaid
TN116432Medicaid
TN3105Medicaid
AR56207OtherBLUE CROSS BLUE SHIELD
MS0120587Medicaid
AR102001001Medicaid
TNC68497Medicare UPIN
TN3188360Medicare ID - Type Unspecified
TN390008249Medicare ID - Type UnspecifiedRAILORAD MEDICARE
TN3105Medicaid
MS0120587Medicaid
TN3188369Medicaid
MO208992313Medicaid