Provider Demographics
NPI:1316030398
Name:HERNDON, CHARLES H JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:HERNDON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:101 N CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8002
Mailing Address - Country:US
Mailing Address - Phone:706-278-8220
Mailing Address - Fax:
Practice Address - Street 1:1104 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2588
Practice Address - Country:US
Practice Address - Phone:706-226-5533
Practice Address - Fax:706-428-0033
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013818207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Not Answered207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA023789OtherBCBS EDI
GA00136991AMedicaid
GA023789OtherBCBS EDI