Provider Demographics
NPI:1962475293
Name:HEREDIA, ROGER R (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:R
Last Name:HEREDIA
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 1:1710 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-6646
Mailing Address - Country:US
Mailing Address - Phone:956-969-2536
Mailing Address - Fax:
Practice Address - Street 1:1710 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6646
Practice Address - Country:US
Practice Address - Phone:956-969-2536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8F2027Medicare PIN
TXC16835Medicare UPIN