Provider Demographics
NPI:1568544971
Name:HERRERA, JORGE A (PHD)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:A
Last Name:HERRERA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 142064
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33114-2064
Mailing Address - Country:US
Mailing Address - Phone:305-445-3222
Mailing Address - Fax:786-235-1074
Practice Address - Street 1:100 MIRACLE MILE
Practice Address - Street 2:SUITE 330
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5430
Practice Address - Country:US
Practice Address - Phone:305-445-3222
Practice Address - Fax:786-235-1074
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 000 3733103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75780UMedicare PIN
FL75780OtherBLUE CROSS\BLUE SHIELD FL