Provider Demographics
NPI:1902873979
Name:HERZOG, WILLIAM R JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:HERZOG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10710 CHARTER DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2858
Mailing Address - Country:US
Mailing Address - Phone:410-997-7979
Mailing Address - Fax:410-997-9231
Practice Address - Street 1:10710 CHARTER DR
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2858
Practice Address - Country:US
Practice Address - Phone:410-997-7979
Practice Address - Fax:410-997-9231
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2017-02-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD41959207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00963606OtherRAILROAD MEDICARE
MD0061936OtherAETNA
MD523202-06OtherCAREFIRST OF MARYLAND
MDV879-0001OtherCAREFIRST GHMSI AND BLUE CHOICE
MD543951500Medicaid
MD131533YCQXMedicare PIN
MDE23087Medicare UPIN