Healthcare Provider Details

I. General information

NPI: 1407846850
Provider Name (Legal Business Name): JAY R BISHOP D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W COUNTRY CLUB RD SUITE#205
ROSWELL NM
88201-5205
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-7593
  • Fax: 575-622-5538
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number46011
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA-1577-10
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: