Basic Information
| Provider Information | |||||||||
| NPI: | 1710984406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | OMAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4438 CENTERVIEW | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102800040 | ||||||||
| FaxNumber: | 2102800060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4438 CENTERVIEW | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102800040 | ||||||||
| FaxNumber: | 2102800060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K4704 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P08432K81 | 05 | TX | MEDICAID | 8815B1 | 01 | TX | WELLMED MEDICARE | OTHER | 101829303 | 01 | TX | WELLMED MEDICAID | OTHER |