1780876540 NPI number — MR. TIMOTHY J VANDERJAGT M.D.

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 1780876540 NPI number — MR. TIMOTHY J VANDERJAGT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERJAGT
Provider First Name:
TIMOTHY
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1780876540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
465 SAINT MICHAELS DR
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-7670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-986-8620
Provider Business Mailing Address Fax Number:
505-820-2461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 SAINT MICHAELS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-7601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-820-5274
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2007

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: 207ZP0102X , with the licence number:  MD2007-0397 , 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: 21079021 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM001G14 . This is a "BCBS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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