Provider Demographics
NPI:1619965779
Name:HERRALD, GORDON A (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:A
Last Name:HERRALD
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 1:22102 E QUARTO PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-7020
Mailing Address - Country:US
Mailing Address - Phone:303-617-3062
Mailing Address - Fax:303-617-3165
Practice Address - Street 1:22102 E QUARTO PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-7020
Practice Address - Country:US
Practice Address - Phone:303-617-3062
Practice Address - Fax:303-617-3165
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19642207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73807524Medicaid
CO803217Medicare PIN
CO73807524Medicaid
COC810299Medicare PIN