Healthcare Provider Details

I. General information

NPI: 1679560163
Provider Name (Legal Business Name): DWIGHT ANTONY HAMILTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 S TELSHOR BLVD SUITE 207
LAS CRUCES NM
88011-4951
US

IV. Provider business mailing address

PO BOX 6310
LAS CRUCES NM
88006-6310
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-6806
  • Fax: 575-521-8033
Mailing address:
  • Phone: 575-556-6400
  • Fax: 575-556-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number20349
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number032747
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD2009-0566
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: