=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770678609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURENCE SHANDLER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 11/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 W ALAMEDA ST STE 25
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-988-8869
-----------------------------------------------------
Fax | 505-982-6298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1418 LUISA STREET SUITE 5
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-690-8436
-----------------------------------------------------
Fax | 505-984-8967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 72227
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------