Healthcare Provider Details

I. General information

NPI: 1588621551
Provider Name (Legal Business Name): ANGELIQUE MARIE HART M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 BISHOPS LODGE RD
SANTA FE NM
87506-0005
US

IV. Provider business mailing address

1530 BISHOPS LODGE RD
SANTA FE NM
87506-0005
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-1293
  • Fax: 505-467-8309
Mailing address:
  • Phone: 505-983-1293
  • Fax: 505-467-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME64653
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD2006-0057
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: