Healthcare Provider Details

I. General information

NPI: 1811020670
Provider Name (Legal Business Name): JEREMY STEWART HERTZIG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE STE 202
JACKSON WY
83001-8640
US

IV. Provider business mailing address

PO BOX 4182
JACKSON WY
83001-4182
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-6520
  • Fax: 307-733-3216
Mailing address:
  • Phone: 802-734-8762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14530A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: