Provider Demographics
NPI:1760019459
Name:KOBZEVA-HERZOG, ANNA JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:JACQUELINE
Last Name:KOBZEVA-HERZOG
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 1:72 EAST CONCORD STREET
Mailing Address - Street 2:COLLAMORE BUILDING, C515
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-638-8442
Mailing Address - Fax:
Practice Address - Street 1:72 EAST CONCORD STREET
Practice Address - Street 2:COLLAMORE BUILDING, C515
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA285405208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program