Provider Demographics
NPI:1710980461
Name:HERSTOFF, JAMES KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KENNETH
Last Name:HERSTOFF
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 1:75 GIBBS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2216
Mailing Address - Country:US
Mailing Address - Phone:401-849-2223
Mailing Address - Fax:
Practice Address - Street 1:75 GIBBS AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2216
Practice Address - Country:US
Practice Address - Phone:401-849-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-25
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD04667207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI900709Medicaid
RI0000000709OtherBLUE CROSS BLUE SHIELD RI
RI900709Medicaid