Provider Demographics
NPI:1427292614
Name:HERZOG, KERI ALISSA (MD)
Entity type:Individual
Prefix:MS
First Name:KERI
Middle Name:ALISSA
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 1:687 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3612
Mailing Address - Country:US
Mailing Address - Phone:203-481-7050
Mailing Address - Fax:203-488-6945
Practice Address - Street 1:1224 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3778
Practice Address - Country:US
Practice Address - Phone:203-481-0315
Practice Address - Fax:203-488-6945
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT54855207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program