Provider Demographics
NPI:1245204502
Name:DEANNA, HERMAN L (OD)
Entity Type:Individual
Prefix:DR
First Name:HERMAN
Middle Name:L
Last Name:DEANNA
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 1:7100 W 20TH AVE STE 702
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1824
Mailing Address - Country:US
Mailing Address - Phone:305-825-3005
Mailing Address - Fax:305-819-5887
Practice Address - Street 1:7100 W 20TH AVE STE 702
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1824
Practice Address - Country:US
Practice Address - Phone:305-825-3005
Practice Address - Fax:305-819-5887
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620097400Medicaid
FL5723570OtherAETNA PIN
FL810468OtherEYEMED PIN
FL810468OtherEYEMED PIN
FL620097400Medicaid