Provider Demographics
NPI:1215983762
Name:HERBOLD, WILLIAM SCOTT (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SCOTT
Last Name:HERBOLD
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 1:1600 9TH STREET
Mailing Address - Street 2:ROOM 205 MAILSTOP 2 3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-3186
Practice Address - Street 1:11401 SOUTH BLOOMFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650
Practice Address - Country:US
Practice Address - Phone:562-863-7011
Practice Address - Fax:562-864-4560
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG570532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F23577Medicare UPIN
00G570530Medicare ID - Type Unspecified