Healthcare Provider Details

I. General information

NPI: 1609828326
Provider Name (Legal Business Name): CHARLES SCHAEFFER HERTZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GALISTEO ST SUITE C
SANTA FE NM
87505-4780
US

IV. Provider business mailing address

1691 GALISTEO ST SUITE C
SANTA FE NM
87505-4780
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-5631
  • Fax: 505-982-5605
Mailing address:
  • Phone: 505-983-5631
  • Fax: 505-982-5605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number13380
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD2011-0092
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: