Provider Demographics
NPI:1700836855
Name:HERZOG, DENNIS A (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:A
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 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3970
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035261207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0705200122OtherBLUE CROSS BLUE SHIELD MI
MI101658376Medicaid
MIB44245Medicare UPIN
MI101658376Medicaid
070000017Medicare PIN
MIP52870001Medicare PIN