Provider Demographics
NPI:1063588820
Name:HERNANDEZ, CELSO ROMAN (MD)
Entity type:Individual
Prefix:
First Name:CELSO
Middle Name:ROMAN
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92140 OVERSEAS HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TAVERNIER
Mailing Address - State:FL
Mailing Address - Zip Code:33070-2636
Mailing Address - Country:US
Mailing Address - Phone:305-852-7473
Mailing Address - Fax:305-852-8962
Practice Address - Street 1:92140 OVERSEAS HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:TAVERNIER
Practice Address - State:FL
Practice Address - Zip Code:33070-2636
Practice Address - Country:US
Practice Address - Phone:305-852-7473
Practice Address - Fax:305-852-8962
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME28458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057246202Medicaid
FL92393AMedicare ID - Type Unspecified
FLD60060Medicare UPIN