Healthcare Provider Details

I. General information

NPI: 1578516811
Provider Name (Legal Business Name): MARK HERBST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1891 EFFIE ST
LOS ANGELES CA
90026-1711
US

IV. Provider business mailing address

1891 EFFIE ST
LOS ANGELES CA
90026-1711
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-2000
  • Fax:
Mailing address:
  • Phone: 323-644-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG59419
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number13321
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: