Healthcare Provider Details

I. General information

NPI: 1053382911
Provider Name (Legal Business Name): ROBERT ROWEN HERZOG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ROBERT HERZOG

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8690 PETALUMA HILL RD
PENNGROVE CA
94951-8734
US

IV. Provider business mailing address

8690 PETALUMA HILL RD
PENNGROVE CA
94951-8734
US

V. Phone/Fax

Practice location:
  • Phone: 707-779-9162
  • Fax:
Mailing address:
  • Phone: 707-779-9162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number35698
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: