Provider Demographics
NPI:1962855916
Name:HERRERA, JOSE D
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:D
Last Name:HERRERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3158 CEDAR GROVE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1708
Mailing Address - Country:US
Mailing Address - Phone:703-899-9918
Mailing Address - Fax:703-281-3203
Practice Address - Street 1:3158 CEDAR GROVE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1708
Practice Address - Country:US
Practice Address - Phone:703-899-9918
Practice Address - Fax:703-281-3203
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications