Provider Demographics
NPI:1316110075
Name:HERNANDEZ, WILLIAM DOMINGO (IDC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DOMINGO
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 TAUSSIG ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1ST BATTALION 4TH MARINES BATTALION AIDE STATION
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5380
Practice Address - Country:US
Practice Address - Phone:760-763-1412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman