Provider Demographics
NPI:1144217654
Name:HERRON, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:HERRON
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 1:1610 N EL DORADO ST
Mailing Address - Street 2:SUITE 17
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5930
Mailing Address - Country:US
Mailing Address - Phone:209-465-5107
Mailing Address - Fax:209-465-7653
Practice Address - Street 1:1610 N EL DORADO ST
Practice Address - Street 2:SUITE 17
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5930
Practice Address - Country:US
Practice Address - Phone:209-465-5107
Practice Address - Fax:209-465-7653
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG10082207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G100820Medicaid
A37844Medicare UPIN
CA00G100820Medicare ID - Type Unspecified