1144200106 NPI number — JOSE A ALICEA MD

Table of content: JOSE A ALICEA MD (NPI 1144200106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144200106 NPI number — JOSE A ALICEA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALICEA
Provider First Name:
JOSE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144200106
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2559 MEDICAL DR STE 3100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMOGORDO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88310-8703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-446-5700
Provider Business Mailing Address Fax Number:
888-987-7176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2559 MEDICAL DR STE 3100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310-8703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-446-5700
Provider Business Practice Location Address Fax Number:
888-987-7176
Provider Enumeration Date:
01/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  97-2 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: J6846 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 46783 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 46783 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 779513 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 96026359 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 124214102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".