Provider Demographics
NPI:1497169247
Name:HERNDON, KAMRI (OD)
Entity Type:Individual
Prefix:
First Name:KAMRI
Middle Name:
Last Name:HERNDON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PROFESSIONAL ACRES DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4340
Mailing Address - Country:US
Mailing Address - Phone:870-333-1087
Mailing Address - Fax:870-333-1088
Practice Address - Street 1:800 PROFESSIONAL ACRES DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4340
Practice Address - Country:US
Practice Address - Phone:870-333-1087
Practice Address - Fax:870-333-1088
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR208327722Medicaid