Provider Demographics
NPI:1700867207
Name:HERRON, MICHAEL K (M D)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:HERRON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8303 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:352-688-8200
Mailing Address - Fax:
Practice Address - Street 1:8303 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5028
Practice Address - Country:US
Practice Address - Phone:352-688-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.11684R2085R0202X
FLME847792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81554OtherBCBS
FLP00060963OtherRR MEDICARE
FLP00352559OtherRR MEDICARE
FL267384300Medicaid
FLP00060963OtherRR MEDICARE
FLU1190YMedicare PIN
FLP00352559OtherRR MEDICARE
FL81554OtherBCBS
FLU1190AMedicare PIN