Provider Demographics
NPI:1073503181
Name:HERTZOG, ROXANNE E (MD)
Entity Type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:E
Last Name:HERTZOG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5908
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-0408
Mailing Address - Country:US
Mailing Address - Phone:206-244-1212
Mailing Address - Fax:206-244-1223
Practice Address - Street 1:1100 PACIFIC AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4261
Practice Address - Country:US
Practice Address - Phone:206-244-1212
Practice Address - Fax:206-244-1223
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032736207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8938073OtherCRIME VICTIMS PROGRAM
WA4682HEOtherREGENCE BLUE SHIELD
WA0184996OtherDEPT OF LABOR & INDUSTRIE
WA8017535Medicaid
WAG8803561Medicare ID - Type UnspecifiedKING COUNTY
WA8017535Medicaid
WA8938073OtherCRIME VICTIMS PROGRAM
WAG07999Medicare UPIN