Healthcare Provider Details

I. General information

NPI: 1801742242
Provider Name (Legal Business Name): ABDUL ANTONGIORGI-RASHAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 ALICIA LN
ROSWELL NM
88201-3319
US

IV. Provider business mailing address

1304 ALICIA LN
ROSWELL NM
88201-3319
US

V. Phone/Fax

Practice location:
  • Phone: 575-246-1685
  • Fax:
Mailing address:
  • Phone: 575-246-1685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number503641585
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: