Provider Demographics
NPI:1124009501
Name:HERRIN, VIRGLE O JR (MD)
Entity type:Individual
Prefix:DR
First Name:VIRGLE
Middle Name:O
Last Name:HERRIN
Suffix:JR
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 1:300 W COUNTRY CLUB RD STE 210
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5240
Mailing Address - Country:US
Mailing Address - Phone:575-625-1292
Mailing Address - Fax:575-624-4836
Practice Address - Street 1:300 W COUNTRY CLUB RD STE 210
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5240
Practice Address - Country:US
Practice Address - Phone:575-625-1292
Practice Address - Fax:575-624-4836
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM80-44207P00000X, 207Q00000X, 208D00000X
FLME107006207P00000X
LAMD203548207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00015068Medicaid
NM274617YTYCMedicare PIN
NM00015068Medicaid