Provider Demographics
NPI:1508021213
Name:HERNANDEZ, HOWARD REVILLA (MD)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:REVILLA
Last Name:HERNANDEZ
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 1:14 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2116
Mailing Address - Country:US
Mailing Address - Phone:617-912-7500
Mailing Address - Fax:617-569-7890
Practice Address - Street 1:14 PORTER ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-2116
Practice Address - Country:US
Practice Address - Phone:617-912-7500
Practice Address - Fax:617-569-7890
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2503772084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry