Provider Demographics
NPI:1982633608
Name:HERNDON, M. BROOKE (MD)
Entity Type:Individual
Prefix:DR
First Name:M.
Middle Name:BROOKE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC. DEPARTMENT OF GENERAL INTERNAL MEDICINE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-4000
Mailing Address - Fax:
Practice Address - Street 1:18 OLD ETNA RD
Practice Address - Street 2:DHMC. DEPARTMENT OF GENERAL INTERNAL MEDICINE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766
Practice Address - Country:US
Practice Address - Phone:603-650-4000
Practice Address - Fax:603-650-4190
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH11316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30201526Medicaid
VT0RE6202Medicaid
NHRE620201Medicare PIN
H38752Medicare UPIN
NHRE620202Medicare PIN