Provider Demographics
NPI:1346238151
Name:HERRERA, J MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:MANUEL
Last Name:HERRERA
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 1:1261 N WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-5154
Mailing Address - Country:US
Mailing Address - Phone:520-722-6858
Mailing Address - Fax:520-722-8781
Practice Address - Street 1:1261 N WILMOT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-5154
Practice Address - Country:US
Practice Address - Phone:520-722-6858
Practice Address - Fax:520-722-8781
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14965174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ276685Medicaid
AZZ70589Medicare Oscar/Certification