Provider Demographics
NPI:1104656321
Name:HERRERA MARTINEZ, MARCO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:HERRERA MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARCO A. HERRERA
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6056 CAMINO LARGO
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3114
Mailing Address - Country:US
Mailing Address - Phone:760-219-3596
Mailing Address - Fax:
Practice Address - Street 1:1501 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-7638
Practice Address - Country:US
Practice Address - Phone:619-233-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)