Provider Demographics
NPI:1528139367
Name:HERTZOG, LEIF M (MD)
Entity type:Individual
Prefix:
First Name:LEIF
Middle Name:M
Last Name:HERTZOG
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 1:5094 E LOS COYOTES DIAGONAL
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-2839
Mailing Address - Country:US
Mailing Address - Phone:562-595-4366
Mailing Address - Fax:562-595-6092
Practice Address - Street 1:5094 E LOS COYOTES DIAGONAL
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-2839
Practice Address - Country:US
Practice Address - Phone:562-597-3100
Practice Address - Fax:562-597-5055
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52761207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E93117Medicare UPIN