Healthcare Provider Details

I. General information

NPI: 1932100559
Provider Name (Legal Business Name): CELSO A HERNANDEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 1ST ST STE 150
BOISE ID
83702-6135
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-3088
  • Fax: 208-381-4314
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number4271191
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: