Healthcare Provider Details

I. General information

NPI: 1194170324
Provider Name (Legal Business Name): ROXANA RAICU, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 BROTHERS RD SUITE B
SANTA FE NM
87505-6975
US

IV. Provider business mailing address

10 CALIENTE RD
SANTA FE NM
87508-9167
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-4480
  • Fax: 505-807-0285
Mailing address:
  • Phone: 505-603-4480
  • Fax: 505-807-0285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number2003-0100
License Number StateNM

VIII. Authorized Official

Name: ROXANA G. RAICU
Title or Position: OWNER
Credential: M.D.
Phone: 505-603-4480