Healthcare Provider Details

I. General information

NPI: 1295778710
Provider Name (Legal Business Name): LEE C CARUANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S 3RD ST
RATON NM
87740-4005
US

IV. Provider business mailing address

411 SOUTH 3RD ST
RATON NM
87740-4041
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-3626
  • Fax: 575-445-8649
Mailing address:
  • Phone: 575-445-3626
  • Fax: 575-445-8649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number90-163
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: