Provider Demographics
NPI:1023181070
Name:HEREDIA, ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:HEREDIA
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 1:1541 E FABYAN PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4105
Mailing Address - Country:US
Mailing Address - Phone:630-845-9644
Mailing Address - Fax:630-260-1049
Practice Address - Street 1:1541 E FABYAN PKWY STE 101
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4105
Practice Address - Country:US
Practice Address - Phone:630-845-9644
Practice Address - Fax:630-845-9678
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360788732084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry