Provider Demographics
NPI:1710047097
Name:HERBST, JAY S (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:S
Last Name:HERBST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2866 TAMIAMI TRL STE A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5165
Mailing Address - Country:US
Mailing Address - Phone:941-764-1055
Mailing Address - Fax:941-764-7984
Practice Address - Street 1:2866 TAMIAMI TRL STE A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5165
Practice Address - Country:US
Practice Address - Phone:941-764-1055
Practice Address - Fax:941-764-7984
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046734207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE68522Medicare UPIN
FL09910Medicare ID - Type UnspecifiedMEDICARE