Provider Demographics
NPI:1033137443
Name:KIRACOFE, GEORGE R (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:R
Last Name:KIRACOFE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5828
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:I-40, EXIT 102
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:505-552-5828
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL22645207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NM320070Medicare Oscar/Certification