Healthcare Provider Details

I. General information

NPI: 1154328094
Provider Name (Legal Business Name): SANTIAGO R. MACIAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 EL CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105-4592
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7400
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2004-0045
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: