Healthcare Provider Details

I. General information

NPI: 1003365941
Provider Name (Legal Business Name): BRYAN HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/27/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 CADILLAC AVE
LOS ANGELES CA
90034-1702
US

IV. Provider business mailing address

710 LAWRENCE EXPY
SANTA CLARA CA
95051-5173
US

V. Phone/Fax

Practice location:
  • Phone: 310-666-6055
  • Fax:
Mailing address:
  • Phone: 310-666-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA163637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: