Provider Demographics
NPI:1811978638
Name:HERZOG, DAVID BRANDEIS (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRANDEIS
Last Name:HERZOG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2 LONGFELLOW PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2437
Mailing Address - Country:US
Mailing Address - Phone:617-726-8470
Mailing Address - Fax:617-726-1595
Practice Address - Street 1:2 LONGFELLOW PL
Practice Address - Street 2:SUITE 200
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2437
Practice Address - Country:US
Practice Address - Phone:617-724-0799
Practice Address - Fax:617-726-1595
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA38347208000000X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0107433Medicaid
MA700650OtherTUFTS HEALTH PLAN
MAM09907OtherBCBS MA
B98766Medicare UPIN
MA0107433Medicaid