Healthcare Provider Details

I. General information

NPI: 1487836672
Provider Name (Legal Business Name): VITTAL T PAI, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 S TELSHOR BLVD
LAS CRUCES NM
88011-5049
US

IV. Provider business mailing address

2415 S TELSHOR BLVD
LAS CRUCES NM
88011-5049
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-7977
  • Fax: 575-522-0930
Mailing address:
  • Phone: 575-522-7977
  • Fax: 575-522-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number74-218
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number74-218
License Number StateNM

VIII. Authorized Official

Name: KRISTIN E SARABIA
Title or Position: RECEPTIONIST
Credential:
Phone: 575-522-7977