Provider Demographics
NPI:1326187055
Name:HEROLD, WILLIAM LEROY (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LEROY
Last Name:HEROLD
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 1:2841 DEBARR RD
Mailing Address - Street 2:SUITE 22
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2932
Mailing Address - Country:US
Mailing Address - Phone:907-276-6301
Mailing Address - Fax:
Practice Address - Street 1:2841 DEBARR RD
Practice Address - Street 2:SUITE 22
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2932
Practice Address - Country:US
Practice Address - Phone:907-276-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK4245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD42453Medicaid
AKMD42453Medicaid
202072667OtherTIN
AKE31829Medicare UPIN
AKK152741Medicare ID - Type UnspecifiedIND ID FOR ERPNW