Provider Demographics
NPI:1578629564
Name:HERRIN, EUGENE VAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:VAN
Last Name:HERRIN
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 1:740 PRINCE AVE
Mailing Address - Street 2:BLDG 3
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5908
Mailing Address - Country:US
Mailing Address - Phone:706-548-4272
Mailing Address - Fax:706-548-9181
Practice Address - Street 1:740 PRINCE AVE
Practice Address - Street 2:BLDG 3
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5908
Practice Address - Country:US
Practice Address - Phone:706-548-4272
Practice Address - Fax:706-548-9181
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA237707OtherBCBS NUMBER
GA00114265BMedicaid
GA00114265BMedicaid
GA237707OtherBCBS NUMBER