Provider Demographics
NPI:1699763896
Name:HERNANDEZ, ENRIQUE (MD)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-3008
Mailing Address - Fax:215-707-1387
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:7TH FL OUT PATIENT BLDG
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3008
Practice Address - Fax:215-707-1387
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037584E207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010883930007Medicaid
C31344Medicare UPIN
PA0010883930007Medicaid