Provider Demographics
NPI:1548420615
Name:IMITOLA HERRERA, JAIME (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:IMITOLA HERRERA
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8031
Mailing Address - Country:US
Mailing Address - Phone:860-679-4888
Mailing Address - Fax:860-679-0131
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-4888
Practice Address - Fax:860-679-0131
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351223462084N0400X
CT0632042084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0093556Medicaid
OH0093556Medicaid