Provider Demographics
NPI:1548263338
Name:HERZOG, RICHARD J (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:HERZOG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 70TH ST
Mailing Address - Street 2:DIVISION OF MRI
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4872
Mailing Address - Country:US
Mailing Address - Phone:212-774-2251
Mailing Address - Fax:212-734-7378
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:DIVISION OF MRI
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:212-774-2251
Practice Address - Fax:212-734-7378
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2061212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02084600Medicaid
NY00637403Medicaid
NY02084600Medicaid
NYHS0W067410Medicare ID - Type UnspecifiedGROUP
NYRH06088710Medicare ID - Type Unspecified
NY00637403Medicaid