Provider Demographics
NPI:1538505060
Name:HERAUD, DIEGO (MD)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:HERAUD
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 1:6068 S APOPKA VINELAND RD STE 10
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4449
Mailing Address - Country:US
Mailing Address - Phone:407-730-7084
Mailing Address - Fax:407-730-7090
Practice Address - Street 1:6068 S APOPKA VINELAND RD STE 10
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-4449
Practice Address - Country:US
Practice Address - Phone:407-730-7084
Practice Address - Fax:407-730-7090
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015065600Medicaid