Healthcare Provider Details

I. General information

NPI: 1609076504
Provider Name (Legal Business Name): DAVID M. MACIAS, M.D., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ROSINA SUITE D
SANTA FE NM
87505-3355
US

IV. Provider business mailing address

1925 ROSINA SUITE D
SANTA FE NM
87505-3355
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: DR. DAVID M MACIAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-984-8206