Healthcare Provider Details

I. General information

NPI: 1205823457
Provider Name (Legal Business Name): RAY C KOLOSSEUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S TELSHOR BLVD
LAS CRUCES NM
88011-4688
US

IV. Provider business mailing address

755 S TELSHOR BLVD
LAS CRUCES NM
88011-4681
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-5666
  • Fax: 505-522-5680
Mailing address:
  • Phone: 505-522-5666
  • Fax: 505-522-5680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number75-185
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: