Healthcare Provider Details

I. General information

NPI: 1164684353
Provider Name (Legal Business Name): JOSE DAVID HERAZO-MAYA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 9TH ST N STE 310
NAPLES FL
34102-5889
US

IV. Provider business mailing address

311 9TH ST N STE 310
NAPLES FL
34102-5889
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-8250
  • Fax: 239-624-8251
Mailing address:
  • Phone: 239-624-8250
  • Fax: 239-624-8251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME129944
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number052191
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number052191
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME129944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: