Healthcare Provider Details

I. General information

NPI: 1033194378
Provider Name (Legal Business Name): DAVID M MACIAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ROSINA ST SUITE D
SANTA FE NM
87505-3357
US

IV. Provider business mailing address

1925 ROSINA ST SUITE D
SANTA FE NM
87505-3357
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-8206
  • Fax: 505-984-8274
Mailing address:
  • Phone: 505-984-8206
  • Fax: 505-984-8274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number76-228
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: