Provider Demographics
NPI:1508859588
Name:HERNDON, MICHAEL DARREN (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DARREN
Last Name:HERNDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:AL
Mailing Address - Zip Code:36250-0529
Mailing Address - Country:US
Mailing Address - Phone:256-892-8135
Mailing Address - Fax:256-892-8138
Practice Address - Street 1:7701 AL HIGHWAY 144
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:AL
Practice Address - Zip Code:36250-5081
Practice Address - Country:US
Practice Address - Phone:256-892-8135
Practice Address - Fax:256-892-8138
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
51519513OtherBLUE CROSS/BLUE SHIELD
G22554Medicare UPIN