Healthcare Provider Details

I. General information

NPI: 1487767562
Provider Name (Legal Business Name): BRIAN ETHERIDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N POPE ST
SILVER CITY NM
88061-5161
US

IV. Provider business mailing address

530 DE MOSS ST
LORDSBURG NM
88045-2618
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-1511
  • Fax: 575-313-8236
Mailing address:
  • Phone: 575-542-2307
  • Fax: 575-313-8235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2007-0195
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: