Provider Demographics
NPI:1780728956
Name:HERSKOWITZ, LEE J (DO)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:J
Last Name:HERSKOWITZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 EDGEWATER ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4049
Mailing Address - Country:US
Mailing Address - Phone:503-378-7526
Mailing Address - Fax:503-585-4278
Practice Address - Street 1:1233 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4049
Practice Address - Country:US
Practice Address - Phone:503-378-7526
Practice Address - Fax:503-585-4278
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO22759208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023015Medicaid
ORR0000WCHJMMedicare PIN
OR023015Medicaid