Healthcare Provider Details

I. General information

NPI: 1720089519
Provider Name (Legal Business Name): FERNANDO J INDACOCHEA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 E. LOHMAN AVE. SUITE A
LAS CRUCES NM
88011
US

IV. Provider business mailing address

4395 ISLETA CT
LAS CRUCES NM
88011-4297
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-9077
  • Fax: 575-532-9221
Mailing address:
  • Phone: 304-902-0443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2012-0871
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: