Provider Demographics
NPI:1699294686
Name:HER, MICHAEL (IDC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8882 PROMENADE NORTH PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-6456
Mailing Address - Country:US
Mailing Address - Phone:559-283-5541
Mailing Address - Fax:
Practice Address - Street 1:UNIT 100281
Practice Address - Street 2:BOX 1 FPO AE 09588-1900
Practice Address - City:BAHRAIN
Practice Address - State:FOREIGN PROVINCE
Practice Address - Zip Code:MANAMA
Practice Address - Country:BH
Practice Address - Phone:559-283-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman