Provider Demographics
NPI:1043235120
Name:HERZON, GARRETT DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:DAVID
Last Name:HERZON
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 1:8631 W 3RD ST
Mailing Address - Street 2:SUITE 440E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-854-1800
Mailing Address - Fax:
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 440E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-854-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 83599207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AH1999854OtherDEA NUMBER
AH1999854OtherDEA NUMBER
CAC43189Medicare UPIN