Healthcare Provider Details

I. General information

NPI: 1174151914
Provider Name (Legal Business Name): DATHAN TSOSIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 07/14/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MEDICINE HORSE DRIVE
TO'HAJIILEE NM
87026
US

IV. Provider business mailing address

PO BOX 3338
CANONCITO NM
87026-3338
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-2571
  • Fax: 505-908-2310
Mailing address:
  • Phone: 505-908-2571
  • Fax: 505-908-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2022-1471
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: