Provider Demographics
NPI:1639832124
Name:GUILLEN HERNANDEZ, LUIS EDUARDO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:EDUARDO
Last Name:GUILLEN HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 AMSTERDAM AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-1719
Mailing Address - Country:US
Mailing Address - Phone:586-219-7577
Mailing Address - Fax:
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-963-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP112080207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty