Provider Demographics
NPI:1376531590
Name:HERNANDEZ, ILEANA (MD)
Entity Type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COULTER RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432-1122
Mailing Address - Country:US
Mailing Address - Phone:315-462-9561
Mailing Address - Fax:315-462-3492
Practice Address - Street 1:2 COULTER RD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432
Practice Address - Country:US
Practice Address - Phone:315-462-9561
Practice Address - Fax:315-462-3492
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205898-1207R00000X
NY205898208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01856817Medicaid
G79434Medicare UPIN
NY01856817Medicaid