Provider Demographics
NPI:1245231976
Name:HERZOG, VINCENT PAUL (DO)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:PAUL
Last Name:HERZOG
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 1:306 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7640
Mailing Address - Country:US
Mailing Address - Phone:207-883-3434
Mailing Address - Fax:207-883-1424
Practice Address - Street 1:306 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7640
Practice Address - Country:US
Practice Address - Phone:207-883-3434
Practice Address - Fax:207-883-1424
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2012-12-12
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
ME1432208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME178380099Medicaid
ME178380099Medicaid