Provider Demographics
NPI:1164407995
Name:HERREN, RICHENDA DAWN (MD)
Entity Type:Individual
Prefix:
First Name:RICHENDA
Middle Name:DAWN
Last Name:HERREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E CLARK BASS BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4282
Mailing Address - Country:US
Mailing Address - Phone:918-421-6846
Mailing Address - Fax:918-421-6875
Practice Address - Street 1:2 E CLARK BASS BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4282
Practice Address - Country:US
Practice Address - Phone:918-421-6846
Practice Address - Fax:918-421-6875
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31002208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200568320AMedicaid
KS100168240BMedicaid
KS100168240BMedicaid