Provider Demographics
NPI:1437618535
Name:HERZOG, BRYAN JEREMY (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JEREMY
Last Name:HERZOG
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 1:4802 PRAIRIE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-3779
Mailing Address - Country:US
Mailing Address - Phone:917-974-0848
Mailing Address - Fax:
Practice Address - Street 1:2555 E 13TH ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-5161
Practice Address - Country:US
Practice Address - Phone:970-810-5675
Practice Address - Fax:970-810-1899
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0072781208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology