Healthcare Provider Details

I. General information

NPI: 1326195009
Provider Name (Legal Business Name): AGDEL J HERNANDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: AGDEL JOSE HERNANDEZ-COLON MD

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST
BRIGHTON MA
02135-2907
US

IV. Provider business mailing address

BMCHS PROVIDER ENROLLMENT 960 MASSACHUSETTS AVE FLR 2
BOS MA
02135
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2102
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number253070
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA09802100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number253070
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number243913
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: