Provider Demographics
NPI:1891410403
Name:HERRERA, JUAN MARTIN (OD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:MARTIN
Last Name:HERRERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 E 3RD AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-5902
Mailing Address - Country:US
Mailing Address - Phone:509-766-1880
Mailing Address - Fax:
Practice Address - Street 1:845 E 3RD AVE STE 11
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-5902
Practice Address - Country:US
Practice Address - Phone:509-766-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61429597152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program