Provider Demographics
NPI:1255330650
Name:HERZOG, JACQUES A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:A
Last Name:HERZOG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-453-0001
Mailing Address - Fax:314-453-0489
Practice Address - Street 1:226 S WOODS MILL RD
Practice Address - Street 2:STE 58W
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-453-0001
Practice Address - Fax:314-453-0489
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR7F68174400000X, 207YX0901X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202326427Medicaid
MO000001102Medicare ID - Type Unspecified
MOA13939Medicare UPIN