Healthcare Provider Details

I. General information

NPI: 1407815798
Provider Name (Legal Business Name): KEVIN E REXROAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3214 PURDUE PL NE
ALBUQUERQUE NM
87106-2124
US

IV. Provider business mailing address

PO BOX 4159
ALBUQUERQUE NM
87196-4159
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-4701
  • Fax: 505-255-4717
Mailing address:
  • Phone: 505-255-4701
  • Fax: 505-255-4717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberNM 2002-0152
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: