MEDICARE: DR. JESUS HERRERA LAO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A72729	CA
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	A72729	CA
3	208VP0014X	Interventional Pain Medicine Physician	A72729	CA
4	208VP0000X	Pain Medicine Physician	A72729	CA

General Provider Information

NPI Number	:	1275571010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESUS HERRERA LAO MD

Provider Business Mailing Address
First Line	:	6699 ALVARADO RD STE 2304
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5241
Country	:	US
Telephone Number	:	619-255-8800
Fax Number	:	619-255-8083

Provider Business Practice Location Address
First Line	:	6699 ALVARADO RD STE 2304
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5241
Country	:	US
Telephone Number	:	619-255-8800
Fax Number	:	619-255-8083

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	08/01/2022

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