Provider Demographics
NPI:1558395467
Name:HEREDIA, DAGOBERTO
Entity Type:Individual
Prefix:
First Name:DAGOBERTO
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ONAGA
Mailing Address - State:KS
Mailing Address - Zip Code:66521-9574
Mailing Address - Country:US
Mailing Address - Phone:785-841-7297
Mailing Address - Fax:
Practice Address - Street 1:346 MAINE ST STE 150
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1393
Practice Address - Country:US
Practice Address - Phone:785-841-7297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS08-002682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103532Medicare ID - Type Unspecified
H04037Medicare UPIN