Healthcare Provider Details

I. General information

NPI: 1205824216
Provider Name (Legal Business Name): GEOFFREY LEO EWING D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

26 PASEO DE PAZ
TIJERAS NM
87059-7456
US

V. Phone/Fax

Practice location:
  • Phone: 801-528-8505
  • Fax:
Mailing address:
  • Phone: 801-528-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number02002552A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number02002552A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number02002552A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: