Provider Demographics
NPI:1356450415
Name:HERZOG, MALCOLM DUGRO (DPM)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:DUGRO
Last Name:HERZOG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5241 S CICERO AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4967
Mailing Address - Country:US
Mailing Address - Phone:773-284-8811
Mailing Address - Fax:773-284-6431
Practice Address - Street 1:5241 S CICERO AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4967
Practice Address - Country:US
Practice Address - Phone:773-284-8811
Practice Address - Fax:773-284-6431
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60001221OtherBC& BS PROVIDER #
ILK16735Medicare ID - Type UnspecifiedCOOK - PROVIDER #
IL60001221OtherBC& BS PROVIDER #
ILT37671Medicare UPIN
IL211509Medicare ID - Type UnspecifiedGROUP DUPAGE COUNTY
ILK16764Medicare ID - Type UnspecifiedDUPAGE PROVIDER NUMBER