Healthcare Provider Details

I. General information

NPI: 1477623213
Provider Name (Legal Business Name): THOMAS JOHN HERR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 RED ROCK DR
GALLUP NM
87301-5683
US

IV. Provider business mailing address

910 E GREEN AVE
GALLUP NM
87301-5515
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7000
  • Fax:
Mailing address:
  • Phone: 505-879-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29497
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: