Healthcare Provider Details

I. General information

NPI: 1255531083
Provider Name (Legal Business Name): MICHAEL R PINCUS DPM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2207 GOLF COURSE RD SE STE A
RIO RANCHO NM
87124-1954
US

IV. Provider business mailing address

2207 GOLF COURSE RD SE STE A
RIO RANCHO NM
87124-1954
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-1500
  • Fax: 505-896-1113
Mailing address:
  • Phone: 505-896-1500
  • Fax: 505-896-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberNM130
License Number StateNM

VIII. Authorized Official

Name: MRS. KATHY PINCUS
Title or Position: MANAGER
Credential:
Phone: 505-896-1500