Provider Demographics
NPI:1285635953
Name:HERBERT, LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:
Last Name:HERBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 FREDERICK DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030
Mailing Address - Country:US
Mailing Address - Phone:212-281-8200
Mailing Address - Fax:212-281-8301
Practice Address - Street 1:2615 FREDERICK BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030
Practice Address - Country:US
Practice Address - Phone:212-281-8200
Practice Address - Fax:212-281-8301
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186982-1207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG41426Medicare UPIN
NY62U881Medicare PIN