Provider Demographics
NPI:1629085519
Name:HERZBERG, ALEX M (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:M
Last Name:HERZBERG
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7238
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:#140
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1697
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21166207X00000X
WI66572-20207X00000X
WAMD60431541207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001920Medicaid
OR276799Medicaid
OR276799Medicaid
R146989Medicare PIN