Provider Demographics
NPI:1104873595
Name:HEREDIA, CARLOS M (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:M
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1982
Mailing Address - Street 2:
Mailing Address - City:MOROVIS
Mailing Address - State:PR
Mailing Address - Zip Code:00687-1982
Mailing Address - Country:US
Mailing Address - Phone:787-862-3939
Mailing Address - Fax:787-862-3939
Practice Address - Street 1:30 CALLE BALDORIOTY
Practice Address - Street 2:
Practice Address - City:MOROVIS
Practice Address - State:PR
Practice Address - Zip Code:00687-3111
Practice Address - Country:US
Practice Address - Phone:787-862-3939
Practice Address - Fax:787-862-3939
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH71038Medicare UPIN
PR0021104Medicare PIN