Provider Demographics
NPI:1982870481
Name:HEROD, JERRELL WAIKA (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRELL
Middle Name:WAIKA
Last Name:HEROD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4900 S MONACO ST STE 210
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3487
Mailing Address - Country:US
Mailing Address - Phone:303-645-0090
Mailing Address - Fax:303-645-0092
Practice Address - Street 1:10103 RIDGEGATE PKWY STE 103
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5524
Practice Address - Country:US
Practice Address - Phone:303-645-0090
Practice Address - Fax:303-645-0092
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO53179207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45979847Medicaid
CO420690YPNQMedicare PIN
CO45979847Medicaid