Healthcare Provider Details

I. General information

NPI: 1043390222
Provider Name (Legal Business Name): SUSAN DIANE THOMAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

IV. Provider business mailing address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

V. Phone/Fax

Practice location:
  • Phone: 505-521-5381
  • Fax: 505-521-5376
Mailing address:
  • Phone: 505-521-5381
  • Fax: 505-521-5376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2002-0189
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: