MEDICARE: DR. FERNANDO J INDACOCHEA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD2012-0871	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720089519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FERNANDO J INDACOCHEA MD

Provider Business Mailing Address
First Line	:	4395 ISLETA CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4297
Country	:	US
Telephone Number	:	304-902-0443
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 E. LOHMAN AVE.
Second Line	:	SUITE A
City	:	LAS CRUCES
State	:	NM
Zip	:	88011
Country	:	US
Telephone Number	:	575-532-9077
Fax Number	:	575-532-9221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	09/22/2020

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