Healthcare Provider Details

I. General information

NPI: 1922602697
Provider Name (Legal Business Name): LUIS MARIANO CABRERA HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 HIGHWAY 34 E STE 3000
NEWNAN GA
30265-6430
US

IV. Provider business mailing address

327 BEACH 19TH ST
FAR ROCKAWAY NY
11691-4423
US

V. Phone/Fax

Practice location:
  • Phone: 770-252-6767
  • Fax:
Mailing address:
  • Phone: 718-869-7000
  • 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 StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number110223
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number105741
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number105741-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: