1356605877 NPI number — DR. GERONIMO MENDOZA URIAS M.D.

Table of content: DR. GERONIMO MENDOZA URIAS M.D. (NPI 1356605877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356605877 NPI number — DR. GERONIMO MENDOZA URIAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA URIAS
Provider First Name:
GERONIMO
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
MENDOZA
Provider Other First Name:
GERONIMO
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356605877
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
721 E HOLLY ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
DEMING
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88030-5245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-546-6010
Provider Business Mailing Address Fax Number:
575-546-4099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 E HOLLY ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
DEMING
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88030-5245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-546-6010
Provider Business Practice Location Address Fax Number:
575-546-4099
Provider Enumeration Date:
06/29/2012

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: 390200000X , with the licence number:  BP10043455 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: MD2015-0230 , 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: 26393 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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