Basic Information
| Provider Information | |||||||||
| NPI: | 1255377438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 819 | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128660819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185870845 | ||||||||
| FaxNumber: | 5185875068 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 MYRTLE ST | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128661036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185870845 | ||||||||
| FaxNumber: | 5185875068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 2143821 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 2657261 | 05 | NY | MEDICAID |