Provider Demographics
NPI:1902809817
Name:HERRICK, ROBERT S (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:HERRICK
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 1:882 W RIALTO AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5658
Mailing Address - Country:US
Mailing Address - Phone:909-820-4051
Mailing Address - Fax:909-820-4053
Practice Address - Street 1:882 W RIALTO AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5658
Practice Address - Country:US
Practice Address - Phone:909-820-4051
Practice Address - Fax:909-820-4053
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
CAC24395207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C243950Medicaid
CA00C243950Medicare ID - Type Unspecified
CA00C243950Medicaid