Healthcare Provider Details

I. General information

NPI: 1356450043
Provider Name (Legal Business Name): MARY E MOYER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/23/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 B VETERANS BLVD
ACOMA NM
87034
US

IV. Provider business mailing address

P.O. BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5385
  • Fax: 505-552-5828
Mailing address:
  • Phone: 505-552-5385
  • Fax: 505-552-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19675
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: