Healthcare Provider Details

I. General information

NPI: 1427294982
Provider Name (Legal Business Name): RODERICK DOUGLAS FARLEY D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 MERISSA LN NE
ALBUQUERQUE NM
87122-3763
US

IV. Provider business mailing address

8001 MERISSA LN NE
ALBUQUERQUE NM
87122-3763
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-0022
  • Fax: 505-822-0055
Mailing address:
  • Phone: 505-822-0022
  • Fax: 505-822-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number233
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberOE1123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: