Healthcare Provider Details

I. General information

NPI: 1437339512
Provider Name (Legal Business Name): LEONEL G. RODARTE M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 FOOTHILLS STE. B
LAS CRUCES NM
88011
US

IV. Provider business mailing address

3885 FOOTHILLS STE. B
LAS CRUCES NM
88011
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5111
  • Fax: 575-522-5115
Mailing address:
  • Phone: 575-522-5111
  • Fax: 575-522-5115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2002-0380
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberNM2002-0380
License Number StateNM

VIII. Authorized Official

Name: LEONEL G. RODARTE
Title or Position: OWNER
Credential: M.D.
Phone: 575-522-5111