Provider Demographics
NPI:1578872826
Name:HERCEG, JUSTIN RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RYAN
Last Name:HERCEG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 CORSHAM CIR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-5905
Mailing Address - Country:US
Mailing Address - Phone:740-632-1497
Mailing Address - Fax:330-400-4275
Practice Address - Street 1:3570 EXECUTIVE DR
Practice Address - Street 2:SUITE 211
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-8712
Practice Address - Country:US
Practice Address - Phone:330-563-4383
Practice Address - Fax:330-563-4874
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1578872826OtherPERSONAL NPI
OHH198420OtherGROUP PTAN
OH1457691834OtherGROUP NPI
OH0078436Medicaid
OHH198421OtherINDIVIUAL PTAN