Provider Demographics
NPI:1851463145
Name:HERSKOVITS, RONNY (MD)
Entity Type:Individual
Prefix:
First Name:RONNY
Middle Name:
Last Name:HERSKOVITS
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 1:505 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729
Mailing Address - Country:US
Mailing Address - Phone:631-243-1313
Mailing Address - Fax:631-243-0323
Practice Address - Street 1:505 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729
Practice Address - Country:US
Practice Address - Phone:631-243-1313
Practice Address - Fax:631-243-0323
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1558571207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00959095Medicaid
NY00959095Medicaid
72D772Medicare ID - Type Unspecified