Provider Demographics
NPI:1750356127
Name:HERBST, BRADLEY A (DPM)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:HERBST
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12276 SAN JOSE BLVD STE 606
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8672
Mailing Address - Country:US
Mailing Address - Phone:904-268-6993
Mailing Address - Fax:904-260-1523
Practice Address - Street 1:12276 SAN JOSE BLVD STE 606
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8672
Practice Address - Country:US
Practice Address - Phone:904-268-6993
Practice Address - Fax:904-260-1523
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2789213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390492000Medicaid
FL65613WMedicare PIN
FL390492000Medicaid
FL65613Medicare PIN