Provider Demographics
NPI:1114134962
Name:HERTZBERG, MARK ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:HERTZBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-0461
Mailing Address - Country:US
Mailing Address - Phone:718-327-1536
Mailing Address - Fax:718-327-1536
Practice Address - Street 1:25301 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3113
Practice Address - Country:US
Practice Address - Phone:516-295-2135
Practice Address - Fax:516-295-4561
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist