Healthcare Provider Details

I. General information

NPI: 1255859047
Provider Name (Legal Business Name): JULIO HEREDIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 SANSOME STREET, 5TH FLOOR
SAN FRANCISCO CA
94104
US

IV. Provider business mailing address

180 SANSOME ST FL 5
SAN FRANCISCO CA
94104-3713
US

V. Phone/Fax

Practice location:
  • Phone: 415-819-8148
  • Fax: 510-922-8737
Mailing address:
  • Phone: 415-819-8148
  • Fax: 510-922-8737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number007462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: