Healthcare Provider Details

I. General information

NPI: 1881870426
Provider Name (Legal Business Name): JUDITH THIERRY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EXIT 102 OFF I-40 1/2 MI SOUTH
SAN FIDEL NM
87049-0130
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5385
  • Fax: 505-552-5473
Mailing address:
  • Phone: 505-552-5385
  • Fax: 505-552-5473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101008729
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: