Healthcare Provider Details

I. General information

NPI: 1629109772
Provider Name (Legal Business Name): CHARLES JAMES MAESTAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PETROGYPH CIRCLE STE. B
POJOAQUE NM
87506-0810
US

IV. Provider business mailing address

5 PETROGLYPH CIR STE B
SANTA FE NM
87506-1001
US

V. Phone/Fax

Practice location:
  • Phone: 505-455-2842
  • Fax: 505-455-2941
Mailing address:
  • Phone: 505-455-2842
  • Fax: 505-455-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number88-216
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: