Healthcare Provider Details

I. General information

NPI: 1821189101
Provider Name (Legal Business Name): BHASKER MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NEEL AVE
SOCORRO NM
87801-4649
US

IV. Provider business mailing address

200 NEEL AVE
SOCORRO NM
87801-4649
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-2940
  • Fax: 575-835-2216
Mailing address:
  • Phone: 575-835-2940
  • Fax: 575-835-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ADDY BHASKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 575-835-2940