Provider Demographics
NPI:1598851651
Name:HERTER, GEOFFREY E (MD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:E
Last Name:HERTER
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 1:520 SAYBROOK ROAD
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-8850
Mailing Address - Fax:860-347-6774
Practice Address - Street 1:520 SAYBROOK ROAD
Practice Address - Street 2:SUITE 100B
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-8850
Practice Address - Fax:860-347-6774
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022275208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00122751Medicaid
B38460Medicare UPIN