Healthcare Provider Details

I. General information

NPI: 1740222025
Provider Name (Legal Business Name): GORKY HERRERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N MALACATE ST
AJO AZ
85321-2254
US

IV. Provider business mailing address

410 N MALACATE ST
AJO AZ
85321-2254
US

V. Phone/Fax

Practice location:
  • Phone: 520-387-5651
  • Fax: 520-387-6036
Mailing address:
  • Phone: 520-387-5651
  • Fax: 520-387-6036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number31471
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31471
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: