Healthcare Provider Details

I. General information

NPI: 1437804408
Provider Name (Legal Business Name): ZIA MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FAIRWAY TER N STE B
CLOVIS NM
88101-3060
US

IV. Provider business mailing address

PO BOX 5032
CLOVIS NM
88102-5032
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-7779
  • Fax: 575-762-3526
Mailing address:
  • Phone: 575-762-7779
  • Fax: 575-762-3526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AHMAD OTHMAN
Title or Position: MANAGER
Credential: MD
Phone: 312-813-6958