Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | OEG002112 | PA |
Y | 152W00000X | Optometrist | OPC 4308 | FL |
NPI | 1003075730 |
---|---|
Provider Name | Diana Catalina Hernandez |
First Address | West Melbourne, FL 32904-1460 |
Second Address | West Melbourne, FL 32904-1460 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2008 |
Last Update Date | 28/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001652100 | (05) | FL |
1901V | BCBS (01) | FL |