Healthcare Provider Details

I. General information

NPI: 1316942030
Provider Name (Legal Business Name): DAVID M HERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21756 STATE ROAD 54 SUITE 102A
LUTZ FL
33549-2905
US

IV. Provider business mailing address

14701 CROYDON PL
TAMPA FL
33618-2160
US

V. Phone/Fax

Practice location:
  • Phone: 813-443-5817
  • Fax: 813-443-5818
Mailing address:
  • Phone: 813-443-5817
  • Fax: 813-443-5818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME61297
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME61297
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: