Provider Demographics
NPI:1376626580
Name:HERTFORD, DOUGLAS EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:HERTFORD
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 1:415 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3200
Mailing Address - Country:US
Mailing Address - Phone:212-779-7189
Mailing Address - Fax:212-898-9011
Practice Address - Street 1:400 E 66TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-9314
Practice Address - Country:US
Practice Address - Phone:212-838-4243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178969-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG02083Medicare UPIN