Provider Demographics
NPI:1891410403
Name:HERRERA, JUAN MARTIN (OD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MARTIN
Last Name:HERRERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 E 3RD AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-5902
Mailing Address - Country:US
Mailing Address - Phone:509-282-0320
Mailing Address - Fax:
Practice Address - Street 1:70 ESTELLA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:WA
Practice Address - Zip Code:99343-9521
Practice Address - Country:US
Practice Address - Phone:509-282-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA61429597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program