Provider Demographics
NPI:1881623486
Name:HERTZ, JEFFREY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:HERTZ
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 1:79 WAWECUS ST
Mailing Address - Street 2:STE 105
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360
Mailing Address - Country:US
Mailing Address - Phone:860-886-0161
Mailing Address - Fax:860-889-5999
Practice Address - Street 1:79 WAWECUS ST
Practice Address - Street 2:STE 105
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-886-0161
Practice Address - Fax:860-889-5999
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023601207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
181413OtherPREFERRED ONE
CT031460OtherHEALTH NET
NLS055OtherOXFORD
CT001236017Medicaid
566780OtherAETNA
CT010023601CT01OtherBCS
732141OtherCONNECTICARE
0804876OtherUNITED HEALTHCARE
0584458002OtherCIGNA
CT180000857Medicare PIN
0804876OtherUNITED HEALTHCARE
181413OtherPREFERRED ONE