Provider Demographics
NPI:1023033461
Name:PAYNE, GEORGE LEE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:LEE
Last Name:PAYNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W MAPLE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6590
Mailing Address - Country:US
Mailing Address - Phone:505-327-4867
Mailing Address - Fax:505-327-5355
Practice Address - Street 1:622 W MAPLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6590
Practice Address - Country:US
Practice Address - Phone:505-327-4867
Practice Address - Fax:505-327-5355
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM99-99207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ7224Medicaid
G77095Medicare UPIN
NMZ7224Medicaid