Healthcare Provider Details

I. General information

NPI: 1972561819
Provider Name (Legal Business Name): LOUIS JACK HERSKOWITZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 MULKEY RD SUITE 1
AUSTELL GA
30106-1122
US

IV. Provider business mailing address

835 COGBURN AVENUE NW SUITE 250
MARIETTA GA
30060-1031
US

V. Phone/Fax

Practice location:
  • Phone: 770-941-1013
  • Fax: 770-941-9418
Mailing address:
  • Phone: 770-422-8815
  • Fax: 770-422-8816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number020546
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: