Healthcare Provider Details

I. General information

NPI: 1750356127
Provider Name (Legal Business Name): BRADLEY A HERBST DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 04/17/2024
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12276 SAN JOSE BLVD STE 606
JACKSONVILLE FL
32223-8672
US

IV. Provider business mailing address

12276 SAN JOSE BLVD STE 606
JACKSONVILLE FL
32223-8672
US

V. Phone/Fax

Practice location:
  • Phone: 904-268-6993
  • Fax: 904-260-1523
Mailing address:
  • Phone: 904-268-6993
  • Fax: 904-260-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO2789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: