1881682912 NPI number — PATRICK SAMORA MD

Table of content: PATRICK SAMORA MD (NPI 1881682912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881682912 NPI number — PATRICK SAMORA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMORA
Provider First Name:
PATRICK
Provider Middle Name:
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:
1881682912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1414 LUISA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-4347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-930-5040
Provider Business Mailing Address Fax Number:
505-930-5041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
465 SAINT MICHAELS DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-7670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-995-2400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2005

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: 207Q00000X , with the licence number:  MD2007-0786 , 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: P00082076 . This is a "TRAVELERS MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: SA666518 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 46682040 . This is a "NEW MEXICO MEDICAID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 840706945159 . This is a "ROCKY MOUNTAIN HEALH PLAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 59577754 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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