Healthcare Provider Details

I. General information

NPI: 1184005860
Provider Name (Legal Business Name): NM OPTIMUM MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S TELSHOR BLVD # C201B
LAS CRUCES NM
88011-8235
US

IV. Provider business mailing address

425 S TELSHOR BLVD # C201B
LAS CRUCES NM
88011-8235
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-1200
  • Fax: 575-288-2063
Mailing address:
  • Phone: 575-522-1200
  • Fax: 575-288-2063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD2012-0160
License Number StateNM

VIII. Authorized Official

Name: DR. MARCOS ESTRADA
Title or Position: PRESIDENT
Credential: MD
Phone: 575-522-1200