Provider Demographics
NPI:1437149473
Name:HERRO, ELLISON F (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLISON
Middle Name:F
Last Name:HERRO
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 1:5133 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1438
Mailing Address - Country:US
Mailing Address - Phone:602-264-8015
Mailing Address - Fax:602-264-2172
Practice Address - Street 1:5115 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1478
Practice Address - Country:US
Practice Address - Phone:602-264-1818
Practice Address - Fax:602-264-2172
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ213257Medicaid
AZD37016Medicare UPIN
AZWDBDC-02Medicare ID - Type Unspecified