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General NPI Number Information
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NPI Number | 1720089519
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Entity Type | Individual
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Provider Name | FERNANDO J INDACOCHEA MD
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Gender | Male
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Dates
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Enumeration Date | 08/03/2005
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Last Update Date | 09/22/2020
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Provider Practice Location Address
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Address Line | 4401 E. LOHMAN AVE. SUITE A
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City | LAS CRUCES
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State | NM
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Zip | 88011
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Country | US
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Telephone | 575-532-9077
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Fax | 575-532-9221
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Provider Business Mailing Address
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Address Line | 4395 ISLETA CT
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City | LAS CRUCES
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State | NM
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Zip | 88011-4297
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Country | US
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Telephone | 304-902-0443
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD2012-0871
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License Number State | NM
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