Provider Demographics
NPI:1093734949
Name:HERZOG, JOHN L SR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:HERZOG
Suffix:SR
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:PO BOX 5368
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-5368
Mailing Address - Country:US
Mailing Address - Phone:662-394-0107
Mailing Address - Fax:662-335-7184
Practice Address - Street 1:1421 E UNION ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3247
Practice Address - Country:US
Practice Address - Phone:662-335-0183
Practice Address - Fax:662-335-7184
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS09800207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS060000624OtherMEDICARE
MS00123017Medicaid
AR126236001Medicaid
AR126236001Medicaid