Provider Demographics
NPI:1609828326
Name:HERTZ, CHARLES SCHAEFFER JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SCHAEFFER
Last Name:HERTZ
Suffix:JR
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 1:1691 GALISTEO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4780
Mailing Address - Country:US
Mailing Address - Phone:505-983-5631
Mailing Address - Fax:505-982-5605
Practice Address - Street 1:1691 GALISTEO ST
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4780
Practice Address - Country:US
Practice Address - Phone:505-983-5631
Practice Address - Fax:505-982-5605
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13380207RG0100X
NMMD2011-0092207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4748210OtherCIGNA HEALTHCARE
TN53765OtherBCBS PROVIDER NUMBER
TN8160OtherTLC PROVIDER NUMBER
TN100006289OtherRAILROAD MEDICARE
TN3187049Medicaid
TN4466329OtherAETNA PROVIDER NUMBER
TN3187049Medicaid
TN53765OtherBCBS PROVIDER NUMBER