1942272208 NPI number — KATHLEEN MEZOFF MD

Table of content: KATHLEEN MEZOFF MD (NPI 1942272208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942272208 NPI number — KATHLEEN MEZOFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEZOFF
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1942272208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 REDROCK DR
Provider Second Line Business Mailing Address:
PFS DEPT
Provider Business Mailing Address City Name:
GALLUP
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87301-5683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-863-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2111 COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLUP
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87301-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-863-1820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2006

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: 2080P0006X , with the licence number:  80-68 , 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: 10002105 . This is a "LOVELACE HEALTH/SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PROVP14495 . This is a "MOLINA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 239922 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM001861 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 13656 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85031326887301A131 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".




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