Basic Information
| Provider Information | |||||||||
| NPI: | 1164684353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERAZO-MAYA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 9TH ST N STE 310 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396248250 | ||||||||
| FaxNumber: | 2396248251 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 9TH ST N STE 310 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396248250 | ||||||||
| FaxNumber: | 2396248251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | ME129944 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 052191 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 052191 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | ME129944 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | JJEOQ | 01 | FL | BCBS | OTHER | IY355Z | 01 | FL | MEDICARE | OTHER | 020542800 | 05 | FL | MEDICAID |