Healthcare Provider Details

I. General information

NPI: 1154961977
Provider Name (Legal Business Name): JEREMIAH B OTERO HAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

3454 ZAFARANO DR STE B
SANTA FE NM
87507-2667
US

IV. Provider business mailing address

3454 ZAFARANO DR STE B
SANTA FE NM
87507-2667
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-1984
  • Fax: 505-474-3078
Mailing address:
  • Phone: 505-988-1984
  • Fax: 505-474-3078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAD0888
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: