Healthcare Provider Details

I. General information

NPI: 1881792950
Provider Name (Legal Business Name): LEO J RASCHBAUM MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5690 SANTA TERESITA BUILDING A, SUITE 4
SANTA TERESA NM
88008
US

IV. Provider business mailing address

1074 COUNTRY CLUB RD BUILDING A, SUITE 4
SANTA TERESA NM
88008-9757
US

V. Phone/Fax

Practice location:
  • Phone: 505-589-3022
  • Fax: 505-589-3021
Mailing address:
  • Phone: 505-589-3022
  • Fax: 505-589-3021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number8588
License Number StateNM

VIII. Authorized Official

Name: DR. LEOPOLD JOSEPH RASCHBAUM
Title or Position: OWNER
Credential: MD
Phone: 505-589-3022