Provider Demographics
NPI:1104885235
Name:HERTZER, JOHN L (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:HERTZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:216-383-6616
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3881
Practice Address - Fax:216-844-5883
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350722272084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2203930Medicaid
OH0943457Medicaid
OH000000224416OtherUNISON
OH000000532997OtherANTHEM
OH363633OtherWELLCARE MEDICAID
OH7032237OtherAETNA
OH0943457Medicaid
OH000000224416OtherUNISON
OH000000532997OtherANTHEM
OHHF0892301Medicare PIN