Provider Demographics
NPI:1760706303
Name:HERSCHBERGER, MARK S (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:HERSCHBERGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 N IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2329
Mailing Address - Country:US
Mailing Address - Phone:760-353-3422
Mailing Address - Fax:760-353-9163
Practice Address - Street 1:428 N IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2329
Practice Address - Country:US
Practice Address - Phone:760-353-3422
Practice Address - Fax:760-353-9163
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 19832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 19832OtherCALIFORNIA MEDICAL LICENSE