Provider Demographics
NPI:1851493688
Name:HERNANDEZ, CECILIA M (MD)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:M
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-204-1893
Mailing Address - Fax:510-649-8287
Practice Address - Street 1:2450 ASHBY AVE RM 5505
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2067
Practice Address - Country:US
Practice Address - Phone:510-204-4444
Practice Address - Fax:510-649-8287
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77974207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77974OtherSTATE LICENSE
CA00G779740Medicaid
00G779741Medicare ID - Type Unspecified
CA00G779740Medicaid