Provider Demographics
NPI:1104897073
Name:MARK D. HERRON, M.D. L.L.C.
Entity type:Organization
Organization Name:MARK D. HERRON, M.D. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-272-7273
Mailing Address - Street 1:7260 HALCYON SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7047
Mailing Address - Country:US
Mailing Address - Phone:334-277-3332
Mailing Address - Fax:334-277-3522
Practice Address - Street 1:7260 HALCYON SUMMIT DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7047
Practice Address - Country:US
Practice Address - Phone:334-277-3332
Practice Address - Fax:334-277-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21157207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529923240Medicaid
AL515-27852Medicare ID - Type Unspecified
AL529923240Medicaid