Healthcare Provider Details

I. General information

NPI: 1417103383
Provider Name (Legal Business Name): SARA BLYTHE HERON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 SARATOGA AVE STE 14
SAN JOSE CA
95129-3427
US

IV. Provider business mailing address

1175 SARATOGA AVE STE 14
SAN JOSE CA
95129-3427
US

V. Phone/Fax

Practice location:
  • Phone: 408-996-7950
  • Fax:
Mailing address:
  • Phone: 408-996-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA112236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: