Provider Demographics
NPI:1255431714
Name:HERB, EDMUND M (OD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:M
Last Name:HERB
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:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-1109
Mailing Address - Country:US
Mailing Address - Phone:719-395-6356
Mailing Address - Fax:
Practice Address - Street 1:115 N TABOR ST
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211-1109
Practice Address - Country:US
Practice Address - Phone:719-395-6356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08010688Medicaid
CO5659480001Medicare NSC
T60828Medicare UPIN
CO08010688Medicaid