Healthcare Provider Details

I. General information

NPI: 1932394962
Provider Name (Legal Business Name): JEFFREY A HEROLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 N TAYLOR DR
SHEBOYGAN WI
53081-1927
US

IV. Provider business mailing address

1526 N TAYLOR DR
SHEBOYGAN WI
53081-1927
US

V. Phone/Fax

Practice location:
  • Phone: 920-803-1598
  • Fax: 920-803-1599
Mailing address:
  • Phone: 920-803-1598
  • Fax: 920-803-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number39578
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number39578
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: