Provider Demographics
NPI:1629164454
Name:HERTZOG, LARS H (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:H
Last Name:HERTZOG
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2977 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806
Mailing Address - Country:US
Mailing Address - Phone:562-426-1773
Mailing Address - Fax:562-427-6228
Practice Address - Street 1:2977 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2445
Practice Address - Country:US
Practice Address - Phone:562-426-1773
Practice Address - Fax:562-427-6228
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71446207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A714460Medicaid
CAA71446Medicare PIN
CA00A714460Medicaid