Provider Demographics
NPI:1790716306
Name:HERRICK, ROBERT RAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAPHAEL
Last Name:HERRICK
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 1:3220 BLUME DR
Mailing Address - Street 2:SUITE 151
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1980
Mailing Address - Country:US
Mailing Address - Phone:510-243-2383
Mailing Address - Fax:
Practice Address - Street 1:3220 BLUME DR
Practice Address - Street 2:SUITE 151
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-1980
Practice Address - Country:US
Practice Address - Phone:510-243-2383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG113292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA38320Medicare UPIN