1316942030 NPI number — DAVID M HERSON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316942030 NPI number — DAVID M HERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERSON
Provider First Name:
DAVID
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316942030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14701 CROYDON PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33618-2160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-443-5817
Provider Business Mailing Address Fax Number:
813-443-5818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21756 STATE ROAD 54
Provider Second Line Business Practice Location Address:
SUITE 102A
Provider Business Practice Location Address City Name:
LUTZ
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33549-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-443-5817
Provider Business Practice Location Address Fax Number:
813-443-5818
Provider Enumeration Date:
06/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X , with the licence number:  ME61297 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: ME61297 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2593507 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4565372 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 720000186 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 58760 . This is a "BCBS OF FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 261340900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 279800 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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