Provider Demographics
NPI:1801909338
Name:HERNDON, OLIVER WYNN (MD)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:WYNN
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 1:500 N LEWIS RUN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15122-3056
Mailing Address - Country:US
Mailing Address - Phone:412-460-1111
Mailing Address - Fax:412-460-1465
Practice Address - Street 1:500 N LEWIS RUN RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15122-3056
Practice Address - Country:US
Practice Address - Phone:412-460-1111
Practice Address - Fax:412-460-1465
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067328L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA204657OtherHEALTH AMERICA
PA210438OtherUPMC
PAP00058817OtherPALMETTO RR MEDICARE
PA0018286180003Medicaid
PA204657OtherHEALTH AMERICA
PA210438OtherUPMC