Provider Demographics
NPI:1982279352
Name:HERAK, TREVOR ALEXANDER
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ALEXANDER
Last Name:HERAK
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 1:30225 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-4829
Mailing Address - Country:US
Mailing Address - Phone:216-246-7832
Mailing Address - Fax:
Practice Address - Street 1:2351 E 22ND ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3111
Practice Address - Country:US
Practice Address - Phone:216-861-6200
Practice Address - Fax:216-363-7490
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH59.000902213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist