Provider Demographics
NPI:1659463784
Name:HERTZMAN, PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:HERTZMAN
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 1:3917 WEST RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2275
Mailing Address - Country:US
Mailing Address - Phone:505-662-2900
Mailing Address - Fax:
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:SUITE 130
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-662-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM72-153207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine