Provider Demographics
NPI:1649492554
Name:HERCEG, MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HERCEG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PINE MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3042
Mailing Address - Country:US
Mailing Address - Phone:607-217-5372
Mailing Address - Fax:607-723-1989
Practice Address - Street 1:33 MITCHELL AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1674
Practice Address - Country:US
Practice Address - Phone:607-723-7586
Practice Address - Fax:607-723-1989
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014046207W00000X
NY247466-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02061489OtherMEDICAID GROUP ID
NYAA0477OtherMEDICARE GROUP PROVIDER
NY02992038Medicaid
NYAA0477OtherMEDICARE GROUP PROVIDER
NYRB8384Medicare PIN