Healthcare Provider Details

I. General information

NPI: 1366566192
Provider Name (Legal Business Name): JASON HERSH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 W 20TH AVE STE 102
HIALEAH FL
33016-5509
US

IV. Provider business mailing address

7704 GREAT OAK DR
LAKE WORTH FL
33467-7109
US

V. Phone/Fax

Practice location:
  • Phone: 305-556-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN 15174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: