Provider Demographics
NPI:1518037175
Name:CALEB W. HERNDON, M.D., PH.D., P.A.
Entity Type:Organization
Organization Name:CALEB W. HERNDON, M.D., PH.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HERNDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-833-1946
Mailing Address - Street 1:347 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3219
Mailing Address - Country:US
Mailing Address - Phone:601-833-1946
Mailing Address - Fax:601-833-3938
Practice Address - Street 1:347 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3219
Practice Address - Country:US
Practice Address - Phone:601-833-1946
Practice Address - Fax:601-833-3938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06643174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015595Medicaid
LA1629804Medicaid
MS462669093OtherBCBS OF MISSISSIPPI
MS462669093OtherBCBS OF MISSISSIPPI
B64091Medicare UPIN
180026025Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MS00015595Medicaid