1306865969 NPI number — KEITH D HERR MD

Table of content: KEITH D HERR MD (NPI 1306865969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306865969 NPI number — KEITH D HERR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERR
Provider First Name:
KEITH
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306865969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31309
Provider Second Line Business Mailing Address:
BLDG A7, STE 7333, UNIT 86
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90031-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-442-8541
Provider Business Mailing Address Fax Number:
323-442-8755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 SAN PABLO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033-5313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-442-8541
Provider Business Practice Location Address Fax Number:
323-442-8755
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  49404 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: A119884 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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