1336322312 NPI number — DR. MARTHA A MORENO- CAMPOS M.D.

Table of content: DR. MARTHA A MORENO- CAMPOS M.D. (NPI 1336322312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336322312 NPI number — DR. MARTHA A MORENO- CAMPOS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO- CAMPOS
Provider First Name:
MARTHA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORENO-CAMPOS
Provider Other First Name:
MARTHA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1336322312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 BRIDGE BLVD SW
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87105-3765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-508-1739
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 BRIDGE BLVD SW
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87105-3765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-508-1739
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2007

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: 207Q00000X , with the licence number:  98-122 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000K6956 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 357569806 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 98-122 . This is a "STATE LIC#" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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