Healthcare Provider Details

I. General information

NPI: 1639185739
Provider Name (Legal Business Name): MARC STEVEN TRAEGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ENCINO PL NE STE 14
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

PO BOX 860
WHITERIVER AZ
85941-0860
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1777
  • Fax: 505-272-2360
Mailing address:
  • Phone: 928-338-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17404
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2018-0258
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: