Healthcare Provider Details

I. General information

NPI: 1881608487
Provider Name (Legal Business Name): CECILIA E. CHAO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 187 JICARILLA SERVICE UNIT
DULCE NM
87528-0187
US

IV. Provider business mailing address

PO BOX 1095 TWO BEAR RUN
CHAMA NM
87520-1095
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3291
  • Fax: 505-759-7294
Mailing address:
  • Phone: 505-756-2582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2005-0220
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: