Provider Demographics
NPI:1083775035
Name:HERIZA, THOMAS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JAMES
Last Name:HERIZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 S. 22ND AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-7054
Mailing Address - Country:US
Mailing Address - Phone:406-585-3584
Mailing Address - Fax:406-534-0411
Practice Address - Street 1:1871 S 22ND AVE STE 3
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7054
Practice Address - Country:US
Practice Address - Phone:406-585-3584
Practice Address - Fax:406-534-0411
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT124362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150582Medicaid
ORG17673Medicare UPIN
ORR101162Medicare ID - Type Unspecified