=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992045207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARTHA G HERRERA DPM PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2013
-----------------------------------------------------
Last Update Date | 01/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9765 SAN JOSE BLVD SUITE 107
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-802-5921
-----------------------------------------------------
Fax | 904-212-2481
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9765 SAN JOSE BLVD SUITE 107
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-802-5921
-----------------------------------------------------
Fax | 904-212-2481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | MRS. MARTHA G HERRERA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 904-802-5921
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO3568
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------