Healthcare Provider Details

I. General information

NPI: 1902863640
Provider Name (Legal Business Name): JERALD JOSEPH LITTLEFIELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CALLE DE LA VUELTA E-104
SANTA FE NM
87505-4819
US

IV. Provider business mailing address

2100 CALLE DE LA VUELTA E-104
SANTA FE NM
87505-4819
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-8831
  • Fax: 505-983-2763
Mailing address:
  • Phone: 505-982-8831
  • Fax: 505-983-2763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberNM92284
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101026463
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: