Healthcare Provider Details

I. General information

NPI: 1558446187
Provider Name (Legal Business Name): SAN JUAN ONCOLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 E 30TH ST
FARMINGTON NM
87401-8900
US

IV. Provider business mailing address

2325 E 30TH ST
FARMINGTON NM
87401-8900
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-6850
  • Fax: 505-564-6890
Mailing address:
  • Phone: 505-564-6850
  • Fax: 505-564-6890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY D NEIDHART
Title or Position: MD, CEO
Credential: MD
Phone: 505-564-6850