Provider Demographics
NPI:1629129986
Name:HERZLICH, DOUGLAS B
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
Last Name:HERZLICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 43RD ST
Mailing Address - Street 2:APT 37M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-6302
Mailing Address - Country:US
Mailing Address - Phone:212-564-1544
Mailing Address - Fax:
Practice Address - Street 1:1120 MORRIS PARK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1400
Practice Address - Country:US
Practice Address - Phone:718-409-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003749-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT51174Medicare UPIN
P38701Medicare ID - Type Unspecified