Provider Demographics
NPI:1932893567
Name:HERSCHBERGER, CHAD ANDREW (OD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ANDREW
Last Name:HERSCHBERGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 INTEGRITY WAY UNIT 209
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-3868
Mailing Address - Country:US
Mailing Address - Phone:574-354-2512
Mailing Address - Fax:
Practice Address - Street 1:999 N CURTIS RD STE 205
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1316
Practice Address - Country:US
Practice Address - Phone:208-373-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004417A152W00000X
390200000X
KY2351DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program