Provider Demographics
NPI:1568490605
Name:HERSKOVITS, EDWARD H (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:H
Last Name:HERSKOVITS
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 1:2825 OAK LAWN AVE UNIT 192749
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4688
Mailing Address - Country:US
Mailing Address - Phone:510-683-9500
Mailing Address - Fax:877-880-2039
Practice Address - Street 1:22 S GREENE ST, DEPT OF RADIOLOGY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG612012085N0700X, 2085R0202X
KY561242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD680551500Medicaid
DC020663300Medicaid
PA059426Medicare ID - Type Unspecified