Provider Demographics
NPI:1639948672
Name:HERRERA ESTRADA, ENRIQUE V (SURGICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:V
Last Name:HERRERA ESTRADA
Suffix:
Gender:M
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 S HIGHLAND AVE APT 4C
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5349
Mailing Address - Country:US
Mailing Address - Phone:708-513-1584
Mailing Address - Fax:
Practice Address - Street 1:6201 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3888
Practice Address - Country:US
Practice Address - Phone:708-636-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23-766246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant