Provider Demographics
NPI:1396834701
Name:HERRERO, NICHOLAS ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:HERRERO
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 1:4915 EMPIRE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2137
Mailing Address - Country:US
Mailing Address - Phone:813-334-9687
Mailing Address - Fax:
Practice Address - Street 1:2035 PROFESSIONAL CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4492
Practice Address - Country:US
Practice Address - Phone:904-272-3200
Practice Address - Fax:904-272-3211
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN8831207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002584200Medicaid
FL002584200Medicaid