Provider Demographics
NPI:1518072438
Name:HERZOG, LAURENCE BRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:BRETT
Last Name:HERZOG
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 N ASSEMBLY ST
Mailing Address - Street 2:CREDENTIAL'S OFFICE, SPOKANE VA MEDICAL CENTER
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6185
Mailing Address - Country:US
Mailing Address - Phone:509-434-7344
Mailing Address - Fax:509-434-7195
Practice Address - Street 1:4815 N ASSEMBLY ST
Practice Address - Street 2:CREDENTIAL'S OFFICE, SPOKANE VA MEDICAL CENTER
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6185
Practice Address - Country:US
Practice Address - Phone:509-434-7344
Practice Address - Fax:509-434-7195
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA000401812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN
33025FMedicare ID - Type Unspecified