Basic Information
| Provider Information | |||||||||
| NPI: | 1295719870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEREDIA | ||||||||
| FirstName: | FRANKLIN | ||||||||
| MiddleName: | O. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1239 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480991239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246600 | ||||||||
| FaxNumber: | 2483241477 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 FULLER DRIVE | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750386521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728705511 | ||||||||
| FaxNumber: | 9728705512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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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 | 207R00000X | K4081 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 106257209 | 05 | TX | MEDICAID | 106257215 | 05 | TX | MEDICAID | 106257222 | 05 | TX | MEDICAID | 84675F | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 106257204 | 05 | TX | MEDICAID | 106257205 | 05 | TX | MEDICAID | 106257219 | 05 | TX | MEDICAID | 106257213 | 05 | TX | MEDICAID | 106257207 | 05 | TX | MEDICAID | 106257221 | 05 | TX | MEDICAID | 106257201 | 05 | TX | MEDICAID | 106257211 | 05 | TX | MEDICAID | 106257216 | 05 | TX | MEDICAID | 106257218 | 05 | TX | MEDICAID |