Healthcare Provider Details

I. General information

NPI: 1053390120
Provider Name (Legal Business Name): DANIEL AGEE COLES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CERRILLOS RD
SANTA FE NM
87505-3554
US

IV. Provider business mailing address

1625 WILDERNESS GATE RD
SANTA FE NM
87505-5919
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-9821
  • Fax:
Mailing address:
  • Phone: 505-982-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2005-0503
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: