Provider Demographics
NPI:1528040672
Name:HERRON, CHARLES BURKHEAD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BURKHEAD
Last Name:HERRON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 TYSON AVE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-4579
Mailing Address - Country:US
Mailing Address - Phone:731-642-0025
Mailing Address - Fax:731-644-0899
Practice Address - Street 1:305 TYSON AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4579
Practice Address - Country:US
Practice Address - Phone:731-642-0025
Practice Address - Fax:731-644-0899
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000007370207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN070014703OtherRAILROAD MEDICARE
TN1520224Medicaid
TNBO2380Medicare UPIN
103I078886Medicare PIN