Provider Demographics
NPI:1265407852
Name:HERTEN, ROBERT JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JEFFREY
Last Name:HERTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R
Other - Middle Name:JEFFREY
Other - Last Name:HERTEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15 SANTA ROSA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1811
Mailing Address - Country:US
Mailing Address - Phone:805-541-2650
Mailing Address - Fax:805-541-4043
Practice Address - Street 1:15 SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1811
Practice Address - Country:US
Practice Address - Phone:805-541-2650
Practice Address - Fax:805-541-4043
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25307207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A253070Medicaid
A24373Medicare UPIN
CAWA25307AMedicare ID - Type Unspecified