Provider Demographics
NPI:1992513071
Name:HERRERA GARCIA, GUSTAVO
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:HERRERA GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5523
Mailing Address - Country:US
Mailing Address - Phone:734-755-4975
Mailing Address - Fax:
Practice Address - Street 1:2508 SE 17TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5523
Practice Address - Country:US
Practice Address - Phone:734-755-4975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic