Provider Demographics
NPI:1932394962
Name:HEROLD, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:HEROLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1526 N TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1927
Mailing Address - Country:US
Mailing Address - Phone:920-803-1598
Mailing Address - Fax:920-803-1599
Practice Address - Street 1:1526 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1927
Practice Address - Country:US
Practice Address - Phone:920-803-1598
Practice Address - Fax:920-803-1599
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39578208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32429800Medicaid
WI32429800Medicaid