Provider Demographics
NPI:1811065030
Name:HEREDIA, MIGUEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:413 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3044
Mailing Address - Country:US
Mailing Address - Phone:410-788-6575
Mailing Address - Fax:410-744-1088
Practice Address - Street 1:413 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-3044
Practice Address - Country:US
Practice Address - Phone:410-788-6575
Practice Address - Fax:410-744-1088
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0004971207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD74623Medicare UPIN
MD4201Medicare ID - Type Unspecified