Provider Demographics
NPI:1477623213
Name:HERR, THOMAS JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:HERR
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 1:910 E GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5515
Mailing Address - Country:US
Mailing Address - Phone:505-879-6169
Mailing Address - Fax:
Practice Address - Street 1:1901 RED ROCK DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5683
Practice Address - Country:US
Practice Address - Phone:505-863-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29497208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000 G2604Medicaid
AZ593865Medicaid
AZH52152Medicare UPIN
8HZ30YMedicare ID - Type Unspecified