Provider Demographics
NPI:1467511568
Name:HERNANDEZ-AVILA, CARLOS ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANTONIO
Last Name:HERNANDEZ-AVILA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 RUSSELL ROAD
Mailing Address - Street 2:CEDARCREST HOSPITAL HUMAN RESOURCES
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111
Mailing Address - Country:US
Mailing Address - Phone:860-666-7621
Mailing Address - Fax:860-594-4900
Practice Address - Street 1:525 RUSSELL ROAD
Practice Address - Street 2:CEDARCREST HOSPITAL HUMAN RESOURCES
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111
Practice Address - Country:US
Practice Address - Phone:860-666-7621
Practice Address - Fax:860-594-4900
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0359212084A0401X, 2084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H29273Medicare UPIN