Provider Demographics
NPI:1639237720
Name:HERTZ, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HERTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4772 KATELLA AVE
Mailing Address - Street 2:#200
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2600
Mailing Address - Country:US
Mailing Address - Phone:562-596-5552
Mailing Address - Fax:562-596-5340
Practice Address - Street 1:4772 KATELLA AVE
Practice Address - Street 2:#200
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2600
Practice Address - Country:US
Practice Address - Phone:562-596-5552
Practice Address - Fax:562-596-5340
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59291207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G59291AMedicare ID - Type Unspecified
E02878Medicare UPIN