Healthcare Provider Details

I. General information

NPI: 1578657946
Provider Name (Legal Business Name): ROBERT W. COBERLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING BLVD NE PMG KASEMAN BEHAVIORAL MEDICINE
ALBUQUERQUE NM
87112-5046
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-291-2536
  • Fax: 505-291-5301
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20020153
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: