Provider Demographics
NPI:1730279944
Name:R JEFFREY HERTEN MD INC
Entity Type:Organization
Organization Name:R JEFFREY HERTEN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:HERTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-541-2650
Mailing Address - Street 1:15 SANTA ROSA STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1811
Mailing Address - Country:US
Mailing Address - Phone:805-541-2650
Mailing Address - Fax:805-541-4043
Practice Address - Street 1:15 SANTA ROSA STREET
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1811
Practice Address - Country:US
Practice Address - Phone:805-541-2650
Practice Address - Fax:805-541-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15523Medicare ID - Type Unspecified