1013020460 NPI number — CHARLES EATON PAGE

Table of content: CHARLES EATON PAGE (NPI 1013020460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013020460 NPI number — CHARLES EATON PAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAGE
Provider First Name:
CHARLES
Provider Middle Name:
EATON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAGE
Provider Other First Name:
CHARLES
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1013020460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87499-6210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-609-2258
Provider Business Mailing Address Fax Number:
505-609-2259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 THREE SPRINGS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81301-8296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-306-7783
Provider Business Practice Location Address Fax Number:
303-306-7753
Provider Enumeration Date:
08/17/2006

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: 207P00000X , with the licence number:  MD2010-0108 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 38249 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89375751 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00290341 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 42682274 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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