Provider Demographics
NPI:1760435952
Name:HERZOG, THOMAS HARRY (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:HARRY
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 1:3 LYON PLACE
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669
Mailing Address - Country:US
Mailing Address - Phone:315-394-7542
Mailing Address - Fax:866-506-5573
Practice Address - Street 1:3 LYON PLACE
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669
Practice Address - Country:US
Practice Address - Phone:315-713-6643
Practice Address - Fax:866-506-5573
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46735207XX0005X
NY255987207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03117948Medicaid
FL041980000Medicaid
NY03193937Medicaid
FL041980000Medicaid