Provider Demographics
NPI:1164400354
Name:HERNDON, TIMOTHY E (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:E
Last Name:HERNDON
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 1:2661 S BEAR CLAW WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4468
Mailing Address - Country:US
Mailing Address - Phone:575-496-1642
Mailing Address - Fax:301-517-9067
Practice Address - Street 1:4351 E LOHMAN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8259
Practice Address - Country:US
Practice Address - Phone:575-532-9077
Practice Address - Fax:575-532-9221
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-210208000000X
IDM-13463208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23209259Medicaid
NMNMAAA0539Medicare UPIN