Provider Demographics
NPI:1053418434
Name:HERRERA MARTELA, JOLANTA A
Entity type:Individual
Prefix:
First Name:JOLANTA
Middle Name:A
Last Name:HERRERA MARTELA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2552 ALDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5306
Mailing Address - Country:US
Mailing Address - Phone:804-526-7990
Mailing Address - Fax:804-526-7905
Practice Address - Street 1:2552 ALDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23834-5306
Practice Address - Country:US
Practice Address - Phone:804-526-7990
Practice Address - Fax:804-526-7905
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010119057Medicaid