Provider Demographics
NPI:1720011414
Name:HERZL-BETZ, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HERZL-BETZ
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 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:600 FITCH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1634
Practice Address - Country:US
Practice Address - Phone:607-734-6544
Practice Address - Fax:607-734-6580
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169700207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01035047Medicaid
NYJ400211065Medicare PIN
NY34684DMedicare PIN
NY01035047Medicaid