1710971015 NPI number — PAUL A VAKSELIS MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710971015 NPI number — PAUL A VAKSELIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAKSELIS
Provider First Name:
PAUL
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:
1710971015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1560
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88004-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-647-8366
Provider Business Mailing Address Fax Number:
505-647-8387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2909 HILLRISE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-522-5888
Provider Business Practice Location Address Fax Number:
505-521-1876
Provider Enumeration Date:
09/01/2005

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: 208600000X , with the licence number:  2000120 , 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: 850466870 . This is a "CHAMPUS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 54770 . This is a "PRESBYTERIAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 74423 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM009426 . This is a "BC/BS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 31557 . This is a "LOVELACE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 850460870 . This is a "CIMARRON SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 020049262 . This is a "RR MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 880110001 . This is a "WPS TRICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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