Healthcare Provider Details

I. General information

NPI: 1447592498
Provider Name (Legal Business Name): MARK LAND GROSSETETE M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2013
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 CAMINO DE VIDA STE 300
SANTA ROSA NM
88435
US

IV. Provider business mailing address

117 CAMINO DE VIDA STE 300
SANTA ROSA NM
88435-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-4311
  • Fax: 575-472-4313
Mailing address:
  • Phone: 575-472-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD2017-0779
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberMD2017-0779
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2017-0779
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMD2017-0779
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 6
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD2017-0779
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: