Basic Information
| Provider Information | |||||||||
| NPI: | 1437418324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERMANSEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | D.O., PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6381 BOIS D'ARC | ||||||||
| Address2: | |||||||||
| City: | GILMER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035762594 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128825220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 46508 | TX | N | Pharmacy Service Providers | Pharmacist | 207L00000X | Q9372 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | BP10046239 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 02005166A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.