Provider Demographics
NPI:1740222025
Name:HERRERA, GORKY (MD)
Entity type:Individual
Prefix:DR
First Name:GORKY
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 1:410 N MALACATE ST
Mailing Address - Street 2:
Mailing Address - City:AJO
Mailing Address - State:AZ
Mailing Address - Zip Code:85321-2254
Mailing Address - Country:US
Mailing Address - Phone:520-387-5651
Mailing Address - Fax:520-387-6036
Practice Address - Street 1:410 N MALACATE ST
Practice Address - Street 2:
Practice Address - City:AJO
Practice Address - State:AZ
Practice Address - Zip Code:85321-2254
Practice Address - Country:US
Practice Address - Phone:520-387-5651
Practice Address - Fax:520-387-6036
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ314712084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ815417Medicaid
AZ107609Medicare PIN
AZH26710Medicare UPIN