Healthcare Provider Details

I. General information

NPI: 1164400354
Provider Name (Legal Business Name): TIMOTHY E HERNDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE SUITE 100
LAS CRUCES NM
88011-8259
US

IV. Provider business mailing address

2661 S BEAR CLAW WAY
MERIDIAN ID
83642-4468
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-9077
  • Fax: 575-532-9221
Mailing address:
  • Phone: 575-496-1642
  • Fax: 301-517-9067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82-210
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM-13463
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: