Healthcare Provider Details

I. General information

NPI: 1639948672
Provider Name (Legal Business Name): ENRIQUE V HERRERA ESTRADA SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2024
Last Update Date: 01/01/2024
Certification Date: 12/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 W 95TH ST
OAK LAWN IL
60453-3888
US

IV. Provider business mailing address

2211 S HIGHLAND AVE APT 4C
LOMBARD IL
60148-5349
US

V. Phone/Fax

Practice location:
  • Phone: 708-636-9393
  • Fax:
Mailing address:
  • Phone: 708-513-1584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number23-766
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: