Provider Demographics
NPI:1972575306
Name:HERNDON, WILLIAM A (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:HERNDON
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 1:1616 S KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3651
Mailing Address - Country:US
Mailing Address - Phone:405-330-0032
Mailing Address - Fax:405-715-8808
Practice Address - Street 1:1616 S KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3651
Practice Address - Country:US
Practice Address - Phone:405-330-0032
Practice Address - Fax:405-715-8808
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14145207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200032512OtherRAILROAD MEDICARE
OK100020620AMedicaid
OK200032512OtherRAILROAD MEDICARE