Provider Demographics
NPI:1639233208
Name:HEREDIA, JOSE REINALDO (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:REINALDO
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:DC
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 2358
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-2358
Mailing Address - Country:US
Mailing Address - Phone:407-240-9500
Mailing Address - Fax:407-240-9501
Practice Address - Street 1:6236 KINGSPOINTE PKWY
Practice Address - Street 2:STE 9
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-6530
Practice Address - Country:US
Practice Address - Phone:407-240-9500
Practice Address - Fax:407-240-9500
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7044111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU59161Medicare UPIN
FL55347AMedicare ID - Type Unspecified