Provider Demographics
NPI:1649271875
Name:HERREN, MATTHEW T (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:HERREN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5935
Mailing Address - Country:US
Mailing Address - Phone:850-477-7042
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:4901 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5935
Practice Address - Country:US
Practice Address - Phone:850-477-7042
Practice Address - Fax:850-474-9060
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8910207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL131511Medicaid
FLC400OtherHEALTH FIRST NETWORK
AL009924355Medicaid
FL267431900Medicaid
AL592-15448OtherBLUE CROSS BLUE SHIELD
FL79033OtherBLUECROSS & BLUESHIELD
FLP000048462OtherRAILROAD MEDICARE
AL59168368OtherBLUECROSS & BLUESHIELD
AL009924355Medicaid
FLP000048462OtherRAILROAD MEDICARE