Basic Information
| Provider Information | |||||||||
| NPI: | 1568647816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERSON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060302212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794477 | ||||||||
| FaxNumber: | 8606794474 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060302212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794477 | ||||||||
| FaxNumber: | 8606794474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2008 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 225459-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 046120 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1649263880 | 01 | CT | NPI, NORWALK HOSPITAL | OTHER |