1073731998 NPI number — DR. MARK CARL HERZBERG DDS

Table of content: DR. MARK CARL HERZBERG DDS (NPI 1073731998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073731998 NPI number — DR. MARK CARL HERZBERG DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERZBERG
Provider First Name:
MARK
Provider Middle Name:
CARL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
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:
1073731998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3927 YORK AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55410-1164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-929-7540
Provider Business Mailing Address Fax Number:
612-626-2651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VA MEDICAL CENTER
Provider Second Line Business Practice Location Address:
ONE VETERANS DRIVE
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-467-4716
Provider Business Practice Location Address Fax Number:
612-626-2651
Provider Enumeration Date:
04/23/2007

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: 1223P0300X , with the licence number:  8687 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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