Provider Demographics
NPI:1598856122
Name:HERSCHER, MARK MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MICHAEL
Last Name:HERSCHER
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:PO BOX 789
Mailing Address - Street 2:145 NE BROADWAY
Mailing Address - City:MYRTLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97457-0117
Mailing Address - Country:US
Mailing Address - Phone:541-863-3146
Mailing Address - Fax:541-863-3226
Practice Address - Street 1:145 NE BROADWAY
Practice Address - Street 2:
Practice Address - City:MYRTLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97457-0117
Practice Address - Country:US
Practice Address - Phone:541-863-3146
Practice Address - Fax:541-863-3226
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO14354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138784Medicaid
OR138784Medicaid
OR106946Medicare ID - Type Unspecified