Provider Demographics
NPI:1205828233
Name:HERRERA, MICHAEL DENNIS (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DENNIS
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 1:2019 GALISTEO ST. STE. G5
Mailing Address - Street 2:GALISTEO CENTER
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2164
Mailing Address - Country:US
Mailing Address - Phone:505-989-9600
Mailing Address - Fax:505-982-3616
Practice Address - Street 1:2019 GALISTEO ST. STE. G5
Practice Address - Street 2:GALISTEO CENTER
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2164
Practice Address - Country:US
Practice Address - Phone:505-989-9600
Practice Address - Fax:505-982-3616
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP6026Medicaid
NM2590987Medicare PIN
NMP6026Medicaid