Healthcare Provider Details

I. General information

NPI: 1386642528
Provider Name (Legal Business Name): JOSE LUIS DE ANDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 ANTHONY DR
ANTHONY NM
88021
US

IV. Provider business mailing address

PO BOX 4530
ANTHONY TX
79821-0047
US

V. Phone/Fax

Practice location:
  • Phone: 505-882-2956
  • Fax: 505-882-1863
Mailing address:
  • Phone: 505-882-2956
  • Fax: 505-882-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2002-1081
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL4904
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: