Provider Demographics
NPI:1053304816
Name:HERTZ, RONALD D (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:D
Last Name:HERTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22201 MOROSS
Mailing Address - Street 2:270
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1136
Mailing Address - Country:US
Mailing Address - Phone:313-343-7280
Mailing Address - Fax:313-343-7921
Practice Address - Street 1:19251 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-3749
Practice Address - Fax:313-343-7921
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010791207RA0000X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4435427Medicaid
MI4435427Medicaid
E78174Medicare UPIN