Healthcare Provider Details

I. General information

NPI: 1417031840
Provider Name (Legal Business Name): HERNAN CIUDAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MISSOURI AVE SUITE 27
LAS CRUCES NM
88011-5075
US

IV. Provider business mailing address

PO BOX 1560
LAS CRUCES NM
88004-1560
US

V. Phone/Fax

Practice location:
  • Phone: 505-521-0630
  • Fax: 505-521-0628
Mailing address:
  • Phone: 505-647-8366
  • Fax: 505-647-8381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number74-17
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: