Provider Demographics
NPI:1821076688
Name:HERWIG, THEODOR THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THEODOR
Middle Name:THOMAS
Last Name:HERWIG
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 1:1 INDEPENDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631
Mailing Address - Country:US
Mailing Address - Phone:508-896-0050
Mailing Address - Fax:508-896-0012
Practice Address - Street 1:1 INDEPENDENCE WAY
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631
Practice Address - Country:US
Practice Address - Phone:508-896-0050
Practice Address - Fax:508-896-0012
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA718001OtherTUFTS
MA01-00760OtherUNITED HEALTHCARE
MA9713531Medicaid
MA7783OtherHARVARD PILGRIM
MAB10032101OtherCIGNA
MAB10032101OtherCIGNA
D92803Medicare UPIN