Healthcare Provider Details

I. General information

NPI: 1235184326
Provider Name (Legal Business Name): DIGESTIVE DISEASE CONSULTANTS OF LAS CRUCES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 E LOHMAN AVE STE B
LAS CRUCES NM
88011-8255
US

IV. Provider business mailing address

4381 E LOHMAN AVE STE B
LAS CRUCES NM
88011-8255
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-7697
  • Fax:
Mailing address:
  • Phone: 575-522-7697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number792
License Number StateNM

VIII. Authorized Official

Name: THOMAS V NATTAKOM
Title or Position: CEO
Credential: MD
Phone: 575-522-7697