Provider Demographics
NPI:1891799318
Name:HEROLD, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:HEROLD
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:PO BOX 742382
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:801-270-3395
Practice Address - Street 1:1160 E 3900 S STE G200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-268-7766
Practice Address - Fax:801-270-3395
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1637071205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11017608OtherUNION PACIFIC RAILROAD
UT15032OtherIHC
UT110176008Medicare PIN
UT15032OtherIHC
UT000012110Medicare PIN