Healthcare Provider Details

I. General information

NPI: 1902809817
Provider Name (Legal Business Name): ROBERT S HERRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/24/2006

III. Provider practice location address

882 W RIALTO AVE
RIALTO CA
92376-5658
US

IV. Provider business mailing address

882 W RIALTO AVE
RIALTO CA
92376-5658
US

V. Phone/Fax

Practice location:
  • Phone: 909-820-4051
  • Fax: 909-820-4053
Mailing address:
  • Phone: 909-820-4051
  • Fax: 909-820-4053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberC24395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: