1225135791 NPI number — DR. ALDEN G COCKBURN MD

Table of content: DR. ALDEN G COCKBURN MD (NPI 1225135791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225135791 NPI number — DR. ALDEN G COCKBURN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COCKBURN
Provider First Name:
ALDEN
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
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:
1225135791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1399 WEIMER ROAD
Provider Second Line Business Mailing Address:
# 600B
Provider Business Mailing Address City Name:
TAOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87571-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-751-0334
Provider Business Mailing Address Fax Number:
505-751-0297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1399 WEIMER ROAD
Provider Second Line Business Practice Location Address:
# 600B
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571-6351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-751-0334
Provider Business Practice Location Address Fax Number:
505-751-0297
Provider Enumeration Date:
09/19/2006

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: 208800000X , with the licence number:  MD2004-0101 , 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: MD2004-0101 . This is a "MEDICAL LIC #" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00NM009M74 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 29805325 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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