Healthcare Provider Details

I. General information

NPI: 1467820928
Provider Name (Legal Business Name): OCTAVIO HERRERA-VERDUGO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 BRECKENRIDGE DR STE 110
LITTLE ROCK AR
72205-1565
US

IV. Provider business mailing address

304 WAINWRIGHT DR
NORTHBROOK IL
60062-1900
US

V. Phone/Fax

Practice location:
  • Phone: 501-391-1741
  • Fax: 501-421-3802
Mailing address:
  • Phone: 847-593-8460
  • Fax: 224-235-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE-3534
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberE-3534
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: