Basic Information
| Provider Information | |||||||||
| NPI: | 1093788374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 WESTCHESTER AVE | ||||||||
| Address2: | THE WESTCHESTER MEDICAL GROUP | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146826538 | ||||||||
| FaxNumber: | 9146826403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 THEALL RD | ||||||||
| Address2: | |||||||||
| City: | RYE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105801404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148488700 | ||||||||
| FaxNumber: | 9146826403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 10/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 151221 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01194325 | 05 | NY | MEDICAID |