Provider Demographics
NPI:1174744064
Name:BRIZUELA, HERNAN R (MD)
Entity type:Individual
Prefix:DR
First Name:HERNAN
Middle Name:R
Last Name:BRIZUELA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 LATHAM PARK
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027
Mailing Address - Country:US
Mailing Address - Phone:215-635-8929
Mailing Address - Fax:215-635-4151
Practice Address - Street 1:8019 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19136-2786
Practice Address - Country:US
Practice Address - Phone:215-694-0469
Practice Address - Fax:215-635-4151
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037850L207VH0002X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA147681GUGMedicare PIN