Basic Information
| Provider Information | |||||||||
| NPI: | 1255582805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRERA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | LAZARO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 83 W MILLER ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218415281 | ||||||||
| FaxNumber: | 4076489879 | ||||||||
| Practice Location | |||||||||
| Address1: | 1920 DON WICKHAM DR | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522417275 | ||||||||
| FaxNumber: | 3522417281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2008 | ||||||||
| LastUpdateDate: | 06/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME103054 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | ME103054 | 01 | FL | MEDICAL LICENSE | OTHER | 002174400 | 05 | FL | MEDICAID |