Provider Demographics
NPI:1104980408
Name:HEREDIA, DAVID L (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:HEREDIA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1500 WILDCAT DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2826
Mailing Address - Country:US
Mailing Address - Phone:361-777-3330
Mailing Address - Fax:361-777-2811
Practice Address - Street 1:601 TEXAN TRL STE 200
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2551
Practice Address - Country:US
Practice Address - Phone:361-808-7200
Practice Address - Fax:361-653-0431
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL8073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1671455Medicaid
TX1671455Medicaid
TX8F8989Medicare PIN