Provider Demographics
NPI:1528281839
Name:HERDA, DOMINIC JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:JAMES
Last Name:HERDA
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 1:801 EL CHORRO WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-5243
Mailing Address - Country:US
Mailing Address - Phone:916-201-0937
Mailing Address - Fax:
Practice Address - Street 1:2130 STOCKTON BLVD BLDG 30
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1337
Practice Address - Country:US
Practice Address - Phone:916-520-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG770982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G770980Medicare ID - Type Unspecified
CAG50024Medicare UPIN