Healthcare Provider Details

I. General information

NPI: 1013919232
Provider Name (Legal Business Name): FUNDADOR L ADAJAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2890 N WILSHIRE BLVD
ROSWELL NM
88201-6514
US

IV. Provider business mailing address

2890 N WILSHIRE BLVD
ROSWELL NM
88201-6514
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-0400
  • Fax: 575-623-1702
Mailing address:
  • Phone: 575-624-0400
  • Fax: 575-623-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2002-0003
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: