Provider Demographics
NPI:1578604039
Name:HERRERA, JOSE DELFIN JR (PCO)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:DELFIN
Last Name:HERRERA
Suffix:JR
Gender:M
Credentials:PCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 COULSON DR
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4767
Mailing Address - Country:US
Mailing Address - Phone:505-838-0800
Mailing Address - Fax:505-838-3999
Practice Address - Street 1:1115 N CALIFORNIA STREET
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:505-838-0800
Practice Address - Fax:505-838-3999
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1572224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88722520Medicaid
NM69676577Medicaid
NMD4005Medicaid