Provider Demographics
NPI:1912095225
Name:HERZOG, LESLIE KAREN (DO)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:KAREN
Last Name:HERZOG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8890 W OAKLAND PARK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7223
Mailing Address - Country:US
Mailing Address - Phone:954-228-2322
Mailing Address - Fax:
Practice Address - Street 1:8890 W OAKLAND PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351
Practice Address - Country:US
Practice Address - Phone:954-228-2322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE31903Medicare UPIN
FL80076Medicare ID - Type Unspecified