Provider Demographics
NPI:1366542961
Name:HERZOG, BRUCE DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DAVID
Last Name:HERZOG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:HERZOG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3555 CLARES ST STE H
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2539
Mailing Address - Country:US
Mailing Address - Phone:831-477-4900
Mailing Address - Fax:831-477-4909
Practice Address - Street 1:3555 CLARES ST STE H
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2539
Practice Address - Country:US
Practice Address - Phone:831-477-4900
Practice Address - Fax:831-477-4909
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8087152W00000X
IA01913152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0086942Medicaid
410014677OtherRAILROAD MEDICARE
910904OtherEYEMED
410014677OtherRAILROAD MEDICARE