Healthcare Provider Details

I. General information

NPI: 1659463784
Provider Name (Legal Business Name): PHILLIP HERTZMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD SUITE 130
LOS ALAMOS NM
87544-2275
US

IV. Provider business mailing address

3917 WEST RD SUITE 130
LOS ALAMOS NM
87544-2275
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-2900
  • Fax:
Mailing address:
  • Phone: 505-662-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number72-153
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: