Provider Demographics
NPI:1457362931
Name:HERNANDEZ ITRIAGO, PABLO I (MD)
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:I
Last Name:HERNANDEZ ITRIAGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:650 LINCOLN ST
Mailing Address - Street 2:DOB 503
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2060
Mailing Address - Country:US
Mailing Address - Phone:508-532-7318
Mailing Address - Fax:508-852-8593
Practice Address - Street 1:19 TACOMA ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3516
Practice Address - Country:US
Practice Address - Phone:508-852-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA70172OtherCMSP
MA90590OtherFALLON SELECT
MA110090943AMedicaid
MA97000901OtherNETWORK HEALTH
MAY10141OtherBCBS-GROUP
MAAA16802OtherHARVARD PILGRIM
MAJ28324OtherBCBS
MA0006767OtherNHP-GROUP
MA1300709Medicaid
MA042485308OtherNETWORK HEALTH-GROUP
MA7674093OtherCIGNA
MA0033107OtherNHP
MA042485308OtherNETWORK HEALTH-GROUP
MA0006767OtherNHP-GROUP
MA90590OtherFALLON SELECT
MAI09459Medicare UPIN
MA110090943AMedicaid