Healthcare Provider Details

I. General information

NPI: 1477788644
Provider Name (Legal Business Name): RURAL RADIOLOGY ASSOCIATES TAOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1397 WEIMAR RD
TAOS NM
87571-6253
US

IV. Provider business mailing address

12687 W CEDAR DR 200
LAKEWOOD CO
80228-2014
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-8883
  • Fax: 303-468-1394
Mailing address:
  • Phone: 303-468-1395
  • Fax: 303-468-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL JOHNSON
Title or Position: CO OWNER
Credential: MD
Phone: 575-758-8883