Provider Demographics
NPI:1275519407
Name:HERCEG, MARKO S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARKO
Middle Name:S
Last Name:HERCEG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:S
Other - Last Name:HERCEG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:90 N BROADWAY STE 207
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533-3200
Mailing Address - Country:US
Mailing Address - Phone:914-419-3936
Mailing Address - Fax:
Practice Address - Street 1:90 N BROADWAY STE 207
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NY
Practice Address - Zip Code:10533-3200
Practice Address - Country:US
Practice Address - Phone:914-419-3936
Practice Address - Fax:914-419-3936
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014306-01103G00000X
CT002541103G00000X, 103TR0400X
NY0143061103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVS1761Medicare PIN
CT680001608Medicare PIN