Provider Demographics
NPI:1124052188
Name:HERTZOG, JAMES MARK (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MARK
Last Name:HERTZOG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 S PINE ST STE F
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3864
Mailing Address - Country:US
Mailing Address - Phone:501-941-2222
Mailing Address - Fax:501-941-2577
Practice Address - Street 1:1004 S PINE ST STE F
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3864
Practice Address - Country:US
Practice Address - Phone:501-941-2222
Practice Address - Fax:501-941-2577
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2584152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR499837373OtherMEDICARE DMERC
AR167794722Medicaid
AR49983OtherMEDICARE DMERC
AR0215420001OtherMEDICARE DMERC REGION C
AR882128OtherHEALTHLINKPPO
ARP00450889OtherRAIL ROAD MEDICARE
AR0215420001OtherMEDICARE DMERC REGION C
AR882128OtherHEALTHLINKPPO