Provider Demographics
NPI:1831148055
Name:HERRERA, JOSE I (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:I
Last Name: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 1:200 HIGH SERVICE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5113
Mailing Address - Country:US
Mailing Address - Phone:401-456-3136
Mailing Address - Fax:401-456-3621
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3136
Practice Address - Fax:401-456-3621
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07625207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7002964Medicaid
RIA60467Medicare UPIN
RI00702964Medicare ID - Type Unspecified