Provider Demographics
NPI:1043241524
Name:HERBST, ROBERT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:HERBST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15725 POMERADO ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2057
Mailing Address - Country:US
Mailing Address - Phone:858-451-8600
Mailing Address - Fax:858-451-8383
Practice Address - Street 1:15725 POMERADO ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2057
Practice Address - Country:US
Practice Address - Phone:858-451-8600
Practice Address - Fax:858-451-8383
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29531207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G295310Medicaid
330510067OtherFEDERAL TAX ID NUMBER
330510067OtherFEDERAL TAX ID NUMBER
CA00G295310Medicaid