Provider Demographics
NPI:1164684353
Name:HERAZO-MAYA, JOSE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:DAVID
Last Name:HERAZO-MAYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 9TH ST N STE 310
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5889
Mailing Address - Country:US
Mailing Address - Phone:239-624-8250
Mailing Address - Fax:239-624-8251
Practice Address - Street 1:311 9TH ST N STE 310
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5889
Practice Address - Country:US
Practice Address - Phone:239-624-8250
Practice Address - Fax:239-624-8251
Is Sole Proprietor?:No
Enumeration Date:2008-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME129944207RC0200X, 207RP1001X
CT052191207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJJEOQOtherBCBS
FLIY355ZOtherMEDICARE
FL020542800Medicaid