Provider Demographics
NPI:1134132228
Name:HERRERA, RAYMOND P (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:P
Last Name:HERRERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6419
Mailing Address - Country:US
Mailing Address - Phone:505-326-2020
Mailing Address - Fax:505-327-5530
Practice Address - Street 1:113 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6419
Practice Address - Country:US
Practice Address - Phone:505-326-2020
Practice Address - Fax:505-327-5530
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP2124Medicaid
NMP2124Medicaid
NM0980580001Medicare ID - Type Unspecified