MEDICARE: OCTAVIO HERRERA-VERDUGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	E-3534	AR
2	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	E-3534	AR

General Provider Information

NPI Number	:	1467820928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OCTAVIO HERRERA-VERDUGO

Provider Business Mailing Address
First Line	:	304 WAINWRIGHT DR
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-1900
Country	:	US
Telephone Number	:	847-593-8460
Fax Number	:	224-235-4652

Provider Business Practice Location Address
First Line	:	1225 BRECKENRIDGE DR STE 110
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-1565
Country	:	US
Telephone Number	:	501-391-1741
Fax Number	:	501-421-3802

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2015
Last Update Date	:	10/23/2018

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