Healthcare Provider Details

I. General information

NPI: 1669796595
Provider Name (Legal Business Name): EFFIE E MEDFORD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2010
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 QUAIL TRL UNIT B
EDGEWOOD NM
87015-7185
US

IV. Provider business mailing address

104 QUAIL TRL UNIT B
EDGEWOOD NM
87015-7185
US

V. Phone/Fax

Practice location:
  • Phone: 505-208-0204
  • Fax: 505-384-7028
Mailing address:
  • Phone: 505-208-0204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number69-167
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: