Basic Information
Provider Information | |||||||||
NPI: | 1932130143 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERNANDEZ | ||||||||
FirstName: | LUIS | ||||||||
MiddleName: | N | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5478 | ||||||||
Address2: |   | ||||||||
City: | THIBODAUX | ||||||||
State: | LA | ||||||||
PostalCode: | 703025478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9854934004 | ||||||||
FaxNumber: | 9854934081 | ||||||||
Practice Location | |||||||||
Address1: | 726 N ACADIA RD | ||||||||
Address2: | SUITE 2400 | ||||||||
City: | THIBODAUX | ||||||||
State: | LA | ||||||||
PostalCode: | 703014847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9854934090 | ||||||||
FaxNumber: | 9854934081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 02/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 15684 | LA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 015684 | LA | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 1359441 | 05 | LA |   | MEDICAID |