Provider Demographics
NPI:1265091136
Name:HEREDIA, MILAGRO ESMERALDA (MD)
Entity type:Individual
Prefix:
First Name:MILAGRO
Middle Name:ESMERALDA
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:954-363-9582
Mailing Address - Fax:954-363-9663
Practice Address - Street 1:608 INGRAHAM AVE
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-4330
Practice Address - Country:US
Practice Address - Phone:863-422-9562
Practice Address - Fax:863-421-3246
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLACN1447208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116755000Medicaid