Provider Demographics
NPI:1962485029
Name:HERZOG, ERICA LYNDRUP (MD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNDRUP
Last Name:HERZOG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GEORGE STREET
Mailing Address - Street 2:6TH FLOOR PO BOX 9805
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:WINCHESTER CHEST CLINIC - FITKIN BUILDING - 2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-785-4198
Practice Address - Fax:203-785-3826
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039625207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001396250Medicaid
I36148Medicare UPIN
CT290000411Medicare ID - Type Unspecified