Provider Demographics
NPI:1366408213
Name:HEREDIA, RAUL (MD)
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:HEREDIA
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:PO BOX 4168
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601
Mailing Address - Country:US
Mailing Address - Phone:502-223-5811
Mailing Address - Fax:502-227-7379
Practice Address - Street 1:1002 LEAWOOD DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601
Practice Address - Country:US
Practice Address - Phone:502-227-7188
Practice Address - Fax:502-227-7379
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35532207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0939806OtherALTERNATE MEDICARE PIN
KY64027345Medicaid
KY611202249OtherEIN
KY611202249OtherEIN
KY64027345Medicaid