Healthcare Provider Details

I. General information

NPI: 1922171123
Provider Name (Legal Business Name): GREGORY K BACA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 CENTRAL AVE SUITE 4
LOS ALAMOS NM
87544-3350
US

IV. Provider business mailing address

112 GRAND CANYON DR
LOS ALAMOS NM
87544-3423
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-5217
  • Fax: 505-747-9696
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD2008-0553
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: