Provider Demographics
NPI:1316942030
Name:HERSON, DAVID M (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:HERSON
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 1:14701 CROYDON PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2160
Mailing Address - Country:US
Mailing Address - Phone:813-443-5817
Mailing Address - Fax:813-443-5818
Practice Address - Street 1:21756 STATE ROAD 54
Practice Address - Street 2:SUITE 102A
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-2905
Practice Address - Country:US
Practice Address - Phone:813-443-5817
Practice Address - Fax:813-443-5818
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61297208VP0000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2593507OtherCIGNA
FL4565372OtherAETNA
FL720000186OtherRAILROAD MEDICARE
FL58760OtherBCBS OF FL
FL261340900Medicaid
FL279800OtherAVMED
FL2593507OtherCIGNA
FL279800OtherAVMED