Healthcare Provider Details

I. General information

NPI: 1538249362
Provider Name (Legal Business Name): IRA C. BERKOWITZ,MD PC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

2019 GALISTEO ST SUITE J-1
SANTA FE NM
87505-2143
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-0446
  • Fax:
Mailing address:
  • Phone: 505-820-0446
  • Fax: 505-820-6142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number82-167
License Number StateNM

VIII. Authorized Official

Name: IRA CHARLES BERKOWITZ
Title or Position: PHYSICIAN/PRESIDENT
Credential: M.D.
Phone: 505-820-0446