Basic Information
Provider Information | |||||||||
NPI: | 1760679708 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VINCENT D HERR MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1359 | ||||||||
Address2: |   | ||||||||
City: | KLAMATH FALLS | ||||||||
State: | OR | ||||||||
PostalCode: | 976010075 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418821540 | ||||||||
FaxNumber: | 5418822583 | ||||||||
Practice Location | |||||||||
Address1: | 7905 S 6TH STREET UNIT B | ||||||||
Address2: |   | ||||||||
City: | KLAMATH FALLS | ||||||||
State: | OR | ||||||||
PostalCode: | 976037153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418834573 | ||||||||
FaxNumber: | 5418834573 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2007 | ||||||||
LastUpdateDate: | 10/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HERR | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: | DEAN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5418834573 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD17256 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 037155 | 05 | OR |   | MEDICAID |