Healthcare Provider Details

I. General information

NPI: 1326230939
Provider Name (Legal Business Name): TAOS MOUNTAIN RADIOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1397 WEIMER RD RADIOLOGY DEPARTMENT
TAOS NM
87571-6284
US

IV. Provider business mailing address

12687 W CEDAR DR SUITE 300
LAKEWOOD CO
80228-2010
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-8883
  • Fax: 505-751-7661
Mailing address:
  • Phone: 303-468-1395
  • Fax: 303-468-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2002-0304
License Number StateNM

VIII. Authorized Official

Name: DR. PAUL EATON JOHNSON
Title or Position: OWNER/PARTNER
Credential: M.D.
Phone: 505-758-8883