Provider Demographics
NPI:1194823237
Name:HERVADA, TERESA (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:HERVADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 CORLEAR AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5180
Mailing Address - Country:US
Mailing Address - Phone:718-543-2700
Mailing Address - Fax:718-601-0965
Practice Address - Street 1:3050 CORLEAR AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5180
Practice Address - Country:US
Practice Address - Phone:718-543-2700
Practice Address - Fax:718-601-0965
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY211433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G56562Medicare UPIN