Provider Demographics
NPI:1043722887
Name:HERZOG, MATTHEW RICHARD (LCGC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:HERZOG
Suffix:
Gender:M
Credentials:LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 CHARLES E YOUNG DR S STE 5506
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8348
Mailing Address - Country:US
Mailing Address - Phone:310-210-4368
Mailing Address - Fax:310-206-5699
Practice Address - Street 1:695 CHARLES E YOUNG DR S STE 5506
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8348
Practice Address - Country:US
Practice Address - Phone:310-210-4368
Practice Address - Fax:310-206-5699
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC000669170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS