Provider Demographics
NPI:1073736302
Name:AVELLA, HERNAN M (MD)
Entity Type:Individual
Prefix:
First Name:HERNAN
Middle Name:M
Last Name:AVELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HERNAN
Other - Middle Name:M
Other - Last Name:AVELLA MACIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:77 WARREN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:617-789-2081
Mailing Address - Fax:617-779-6798
Practice Address - Street 1:77 WARREN ST FL 2
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-789-2081
Practice Address - Fax:617-779-6798
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA277500207RP1001X
IDM10843207RP1001X
FLME98374208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAF566ZMedicare Oscar/Certification
ID200002855Medicare PIN
FLAF566ZMedicare PIN