Healthcare Provider Details

I. General information

NPI: 1245763929
Provider Name (Legal Business Name): IDOC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9935 COORS BYP NW STE B
ALBUQUERQUE NM
87114-6195
US

IV. Provider business mailing address

9935 COORS BYP NW STE B
ALBUQUERQUE NM
87114-6195
US

V. Phone/Fax

Practice location:
  • Phone: 505-835-2667
  • Fax: 505-835-2697
Mailing address:
  • Phone: 505-835-2667
  • Fax: 505-370-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNM

VIII. Authorized Official

Name: WILLIS SHERMAN MUNCEY
Title or Position: OPTOMETRIST
Credential:
Phone: 505-417-5398