Healthcare Provider Details

I. General information

NPI: 1043388671
Provider Name (Legal Business Name): ST MARTIN DE PORRES EYE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 SOUTH COLUMBUS RD
DEMING NM
88030
US

IV. Provider business mailing address

1208 SOUTH COLUMBUS RD
DEMING NM
88030
US

V. Phone/Fax

Practice location:
  • Phone: 505-544-0048
  • Fax: 505-544-0165
Mailing address:
  • Phone: 505-544-0048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2002-0264
License Number StateNM

VIII. Authorized Official

Name: THOMAS M BOYLE
Title or Position: OWNER
Credential: MD
Phone: 505-544-0048