Healthcare Provider Details

I. General information

NPI: 1619321809
Provider Name (Legal Business Name): CARL LEWIS HERNDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST PH 11-1120
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST PH 11-1120
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-5976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2021-01325
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number314727-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: