Provider Demographics
NPI:1619909850
Name:HERZOG, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:HERZOG
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 1:237 WILLIAM HOWARD TAFT, PHYS DIV
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-585-2323
Mailing Address - Fax:513-585-4893
Practice Address - Street 1:2139 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-585-2323
Practice Address - Fax:513-585-4893
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231790-1207VX0201X
OH35 057399207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0107031OtherMEDICAID
KY7100315370OtherMEDICAID
NY02561113Medicaid
IN201249540OtherMEDICAID
OH0107031OtherMEDICAID
NY02561113Medicaid