Healthcare Provider Details

I. General information

NPI: 1710119953
Provider Name (Legal Business Name): DARREN T HERZOG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E OAK AVE STE 101
FLAGSTAFF AZ
86001-1818
US

IV. Provider business mailing address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-7880
  • Fax: 928-779-7895
Mailing address:
  • Phone: 928-213-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMED-PHYS-LIC-50222
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number50222
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301092372
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMED-PHYS-LIC-50222
License Number StateMT
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number75684
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: