Healthcare Provider Details

I. General information

NPI: 1760438196
Provider Name (Legal Business Name): JOHN ANDAZOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 S ALAMEDA BLVD
LAS CRUCES NM
88005-2818
US

IV. Provider business mailing address

385 CALLE DE ALEGRA STE A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-528-6400
  • Fax: 575-521-7199
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number99-154
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: