Healthcare Provider Details

I. General information

NPI: 1568465862
Provider Name (Legal Business Name): DAVID L DEETZ D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

710 S ALAMEDA BLVD
LAS CRUCES NM
88005-2928
US

IV. Provider business mailing address

710 S ALAMEDA BLVD
LAS CRUCES NM
88005-2928
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-8566
  • Fax: 575-525-2065
Mailing address:
  • Phone: 575-523-8566
  • Fax: 575-525-2065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberNM142
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: