Healthcare Provider Details

I. General information

NPI: 1508021213
Provider Name (Legal Business Name): HOWARD REVILLA HERNANDEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 PORTER ST
BOSTON MA
02128-2116
US

IV. Provider business mailing address

14 PORTER ST
BOSTON MA
02128-2116
US

V. Phone/Fax

Practice location:
  • Phone: 617-912-7500
  • Fax: 617-569-7890
Mailing address:
  • Phone: 617-912-7500
  • Fax: 617-569-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number250377
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number250377
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: