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General NPI Number Information
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NPI Number | 1518123611
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Entity Type | Organization
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Legal Business Name | SOUTHEWESNT OB/GYN
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Dates
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Enumeration Date | 07/29/2008
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Last Update Date | 07/29/2008
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Provider Practice Location Address
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Address Line | 622 W MAPLE ST STE I
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City | FARMINGTON
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State | NM
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Zip | 87401-6589
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Country | US
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Telephone | 505-325-4898
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Fax | 505-325-7898
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Provider Business Mailing Address
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Address Line | 622 W MAPLE ST STE I
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City | FARMINGTON
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State | NM
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Zip | 87401-6589
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Country | US
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Telephone | 505-325-4898
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Fax | 505-325-7898
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Authorized Official
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Title or Position | DOCTOR
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Name | MARK FISHER
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Credential | M.D.
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Telephone | 505-325-4898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 680659818
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License Number State | NM
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