Provider Demographics
NPI:1598797474
Name:HERZOG, CHRISTOPHER F (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:F
Last Name:HERZOG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9463 HOLLY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2557
Mailing Address - Country:US
Mailing Address - Phone:810-603-2020
Mailing Address - Fax:810-603-2042
Practice Address - Street 1:9463 HOLLY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2557
Practice Address - Country:US
Practice Address - Phone:810-603-2020
Practice Address - Fax:810-603-2042
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009262207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2969290Medicaid
MI0714060001Medicare NSC
MIE36600Medicare UPIN
MI5250906Medicare ID - Type Unspecified