Provider Demographics
NPI:1831231927
Name:HERRING, CHARLES L (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:HERRING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9789
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-2189
Mailing Address - Country:US
Mailing Address - Phone:310-577-8500
Mailing Address - Fax:310-305-7119
Practice Address - Street 1:8930 S SEPULVEDA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3624
Practice Address - Country:US
Practice Address - Phone:310-641-8111
Practice Address - Fax:310-337-7274
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84865207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA006848650Medicaid
CA006848650Medicaid