Healthcare Provider Details

I. General information

NPI: 1831306570
Provider Name (Legal Business Name): SANDIA OBGYN ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 MONTGOMERY BLVD NE SUITE 105
ALBUQUERQUE NM
87109-1226
US

IV. Provider business mailing address

4705 MONTGOMERY BLVD NE SUITE 105
ALBUQUERQUE NM
87109-1226
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-3280
  • Fax: 505-727-3282
Mailing address:
  • Phone: 505-727-3280
  • Fax: 505-727-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA913-90
License Number StateNM

VIII. Authorized Official

Name: DR. CARL JOHN CONNORS
Title or Position: PRESIDENT
Credential: D.O.
Phone: 505-727-3280