Provider Demographics
NPI:1497169700
Name:HERRERA, SURAYDA JULISSA (DO)
Entity type:Individual
Prefix:
First Name:SURAYDA
Middle Name:JULISSA
Last Name:HERRERA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 STANLEY DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2623
Mailing Address - Country:US
Mailing Address - Phone:516-410-4367
Mailing Address - Fax:
Practice Address - Street 1:5 FOUNDERS ST STE 100
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2049
Practice Address - Country:US
Practice Address - Phone:860-423-9764
Practice Address - Fax:860-724-2580
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0005341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine