Healthcare Provider Details

I. General information

NPI: 1508151978
Provider Name (Legal Business Name): STACEY DIMITT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 E ROOSEVELT AVE
GRANTS NM
87020-2245
US

IV. Provider business mailing address

1423 E ROOSEVELT AVE
GRANTS NM
87020-2245
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-6500
  • Fax: 505-287-5393
Mailing address:
  • Phone: 505-287-6500
  • Fax: 505-287-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7613
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: