Healthcare Provider Details

I. General information

NPI: 1376704221
Provider Name (Legal Business Name): JORDANA MANNY HERSCHTHAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7280 W PALMETTO PARK RD STE 210
BOCA RATON FL
33433-3412
US

IV. Provider business mailing address

1475 NW 12TH AVE 2ND FLOOR MOHS UNIT
MIAMI FL
33136-1002
US

V. Phone/Fax

Practice location:
  • Phone: 561-391-9200
  • Fax: 561-338-7027
Mailing address:
  • Phone: 305-243-6704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME111839
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: