Provider Demographics
NPI:1235154758
Name:HERNDON, MILTON BOYD (DO PA)
Entity Type:Individual
Prefix:DR
First Name:MILTON
Middle Name:BOYD
Last Name:HERNDON
Suffix:
Gender:M
Credentials:DO PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:886 SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:PORT NECHES
Mailing Address - State:TX
Mailing Address - Zip Code:77651-5607
Mailing Address - Country:US
Mailing Address - Phone:406-729-6401
Mailing Address - Fax:409-729-6015
Practice Address - Street 1:886 SIERRA DR
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651-5607
Practice Address - Country:US
Practice Address - Phone:406-729-6401
Practice Address - Fax:409-729-6015
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9118207YS0123X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168285801Medicaid
TX120264005Medicaid
00190XMedicare ID - Type Unspecified
TX120264005Medicaid