Provider Demographics
NPI:1619314580
Name:HERTZBERG, LEONARD J (MD, PO)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:J
Last Name:HERTZBERG
Suffix:
Gender:M
Credentials:MD, PO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 BEDFORD AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3737
Mailing Address - Country:US
Mailing Address - Phone:410-484-1344
Mailing Address - Fax:410-415-5711
Practice Address - Street 1:1314 BEDFORD AVE STE 109
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-3737
Practice Address - Country:US
Practice Address - Phone:410-484-1344
Practice Address - Fax:410-415-5711
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0053172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD77726Medicare UPIN