Provider Demographics
NPI:1649597485
Name:RAUL J HERRADA MD PA
Entity Type:Organization
Organization Name:RAUL J HERRADA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEISY
Authorized Official - Middle Name:H
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-896-4147
Mailing Address - Street 1:2177 EAST MICHIGAN STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4948
Mailing Address - Country:US
Mailing Address - Phone:407-896-4147
Mailing Address - Fax:407-895-7182
Practice Address - Street 1:2177 E MICHIGAN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4948
Practice Address - Country:US
Practice Address - Phone:407-896-4147
Practice Address - Fax:407-895-7182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0026137207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038505100Medicaid
FLD55559Medicare UPIN
FL49038Medicare PIN