Provider Demographics
NPI:1316986193
Name:HERRERA, JORGE L (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:HERRERA
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 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-660-5555
Mailing Address - Fax:251-660-5559
Practice Address - Street 1:75 S UNIVERSITY BLVD
Practice Address - Street 2:UCOM 6000 B
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36688-0002
Practice Address - Country:US
Practice Address - Phone:251-660-5555
Practice Address - Fax:251-660-5559
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14475207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000080733Medicaid
MS00121491Medicaid
FL255637500Medicaid
AL29-10130OtherUNITED HEALTH CARE
AL51080733OtherBLUE CROSS
AL51080733OtherBLUE CROSS
GA110027894Medicare ID - Type UnspecifiedPGBA RAILROAD
FL255637500Medicaid