Healthcare Provider Details

I. General information

NPI: 1750425542
Provider Name (Legal Business Name): RAYMOND K HERR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 MORAGA AVE STE B103
SAN DIEGO CA
92117-5352
US

IV. Provider business mailing address

3636 5TH AVE STE 300
SAN DIEGO CA
92103-4230
US

V. Phone/Fax

Practice location:
  • Phone: 858-799-0855
  • Fax: 858-795-1195
Mailing address:
  • Phone: 619-814-5500
  • Fax: 619-794-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberG73544
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number31138
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG73544
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number31138
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: