Healthcare Provider Details

I. General information

NPI: 1649395039
Provider Name (Legal Business Name): ALEXANDER MATTHEWS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E. NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-726-8557
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46247
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2011-0551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: