Basic Information
Provider Information | |||||||||
NPI: | 1316986193 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERRERA | ||||||||
FirstName: | JORGE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40480 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366400480 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516605555 | ||||||||
FaxNumber: | 2516605559 | ||||||||
Practice Location | |||||||||
Address1: | 75 S UNIVERSITY BLVD | ||||||||
Address2: | UCOM 6000 B | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366880002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516605555 | ||||||||
FaxNumber: | 2516605559 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 05/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 14475 | AL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 000080733 | 05 | AL |   | MEDICAID | 00121491 | 05 | MS |   | MEDICAID | 255637500 | 05 | FL |   | MEDICAID | 29-10130 | 01 | AL | UNITED HEALTH CARE | OTHER | 51080733 | 01 | AL | BLUE CROSS | OTHER |