Provider Demographics
NPI:1982861050
Name:HERRERA, JOHANY (MD)
Entity Type:Individual
Prefix:
First Name:JOHANY
Middle Name:
Last Name:HERRERA
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:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-2834
Mailing Address - Fax:432-640-2897
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5001
Practice Address - Country:US
Practice Address - Phone:432-640-2834
Practice Address - Fax:432-640-2897
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048404207Q00000X
TXN7104207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365585YT1YMedicare PIN