Provider Demographics
NPI:1356504385
Name:HERZOG, KATHERINE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:HERZOG
Suffix:
Gender:F
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:PO BOX 74008272
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-8272
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:14855 N OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2026
Practice Address - Country:US
Practice Address - Phone:702-899-0595
Practice Address - Fax:702-977-1496
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7647208100000X
MO2013027011208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1356504385Medicaid
MOMA5459002Medicare PIN