Provider Demographics
NPI:1720181282
Name:HERNANDEZ VELASCO, BENJAMIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:A
Last Name:HERNANDEZ VELASCO
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 1:200 W CENTER STREET PROMENADE STE 400
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:1165 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4801
Practice Address - Country:US
Practice Address - Phone:707-547-5437
Practice Address - Fax:707-547-5430
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13840207R00000X, 208000000X, 208M00000X
CAC150323207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH53082Medicare UPIN
PR84341Medicare ID - Type Unspecified