Provider Demographics
NPI:1942588926
Name:HERRIOTT, MICHAEL BLUE (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLUE
Last Name:HERRIOTT
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 1:5607 JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-4499
Mailing Address - Country:US
Mailing Address - Phone:813-885-3937
Mailing Address - Fax:
Practice Address - Street 1:3324 W UNIVERSITY AVE STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2540
Practice Address - Country:US
Practice Address - Phone:352-240-0801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1613-646T152W00000X
FLOPC5041152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist