=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578738381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALDEN G COCKBURN MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2008
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1399 WEIMER RD # 600
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-6340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-751-0334
-----------------------------------------------------
Fax | 575-751-0297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1399 WEIMER RD # 600
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-6340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-751-0334
-----------------------------------------------------
Fax | 575-751-0297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | JUDY R COCKBURN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-751-0334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 20040101
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------