Provider Demographics
NPI:1053302836
Name:HERALD, CARLTON WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:CARLTON
Middle Name:WAYNE
Last Name:HERALD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25717-1680
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5533
Practice Address - Fax:740-441-3318
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.007166207P00000X, 207R00000X
WV1984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2005609000Medicaid
OH2168890Medicaid
WV00427029OtherRR MEDICARE
KY64071467Medicaid
WVH08203Medicare UPIN
WV2028123Medicare PIN
WV00427029OtherRR MEDICARE
WV2028122Medicare PIN