Provider Demographics
NPI:1992045207
Name:MARTHA G HERRERA DPM PA
Entity Type:Organization
Organization Name:MARTHA G HERRERA DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:G
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-802-5921
Mailing Address - Street 1:9765 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257
Mailing Address - Country:US
Mailing Address - Phone:904-802-5921
Mailing Address - Fax:904-212-2481
Practice Address - Street 1:9765 SAN JOSE BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257
Practice Address - Country:US
Practice Address - Phone:904-802-5921
Practice Address - Fax:904-212-2481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-22
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3568213ES0103X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty