Healthcare Provider Details

I. General information

NPI: 1558562496
Provider Name (Legal Business Name): MACEY BRAY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAPLE STREET
FARMINGTON NM
87401
US

IV. Provider business mailing address

PO BOX 2019
FARMINGTON NM
87499-2019
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-0011
  • Fax: 505-272-5821
Mailing address:
  • Phone: 505-325-1572
  • Fax: 505-327-4887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA-1541-10
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: