Provider Demographics
NPI:1568647816
Name:HERSON, SUSAN ANN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:HERSON
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-4477
Mailing Address - Fax:860-679-4474
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:PROVIDER ENROLLMENT
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2212
Practice Address - Country:US
Practice Address - Phone:860-679-4477
Practice Address - Fax:860-679-4474
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225459-1207R00000X
CT046120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1649263880OtherNPI, NORWALK HOSPITAL