Provider Demographics
NPI:1750425542
Name:HERR, RAYMOND K (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:K
Last Name:HERR
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 1:3636 5TH AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4230
Mailing Address - Country:US
Mailing Address - Phone:619-814-5500
Mailing Address - Fax:619-794-0260
Practice Address - Street 1:3737 MORAGA AVE STE B103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5352
Practice Address - Country:US
Practice Address - Phone:858-799-0855
Practice Address - Fax:858-795-1195
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73544208D00000X, 2083S0010X
CO311382083S0010X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97227579Medicaid
007644OtherKAISER-COMMERCIAL NUMBER
COCK10689Medicare PIN
COCO307460Medicare PIN
007644OtherKAISER-COMMERCIAL NUMBER