Healthcare Provider Details

I. General information

NPI: 1740377290
Provider Name (Legal Business Name): JAMEELA BAI TIKU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S 3RD ST
RATON NM
87740-3910
US

IV. Provider business mailing address

PO BOX 968
RATON NM
87740-0968
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-5548
  • Fax: 575-445-5560
Mailing address:
  • Phone: 575-445-5548
  • Fax: 575-445-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number76-108
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: