Provider Demographics
NPI:1760443725
Name:HERTZ, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:HERTZ
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 1:1498 SOUTHGATE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015
Mailing Address - Country:US
Mailing Address - Phone:650-755-4492
Mailing Address - Fax:650-755-4466
Practice Address - Street 1:1498 SOUTHGATE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015
Practice Address - Country:US
Practice Address - Phone:650-755-4492
Practice Address - Fax:650-755-4466
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG19222207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G192220Medicaid
CA00G192220Medicaid
A40571Medicare UPIN