Provider Demographics
NPI:1083698435
Name:FREZZA, ERMENEGILDO E (MD)
Entity Type:Individual
Prefix:DR
First Name:ERMENEGILDO
Middle Name:E
Last Name:FREZZA
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 1:311 W COUNTRY CLUB RD
Mailing Address - Street 2:STE 1
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5839
Mailing Address - Country:US
Mailing Address - Phone:575-625-3400
Mailing Address - Fax:575-625-3415
Practice Address - Street 1:311 W COUNTRY CLUB RD
Practice Address - Street 2:STE 1
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5839
Practice Address - Country:US
Practice Address - Phone:575-625-3400
Practice Address - Fax:575-625-3415
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1684208600000X
NMMD2006-0035208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159122407Medicaid
TX159122407Medicaid
NM41775732Medicaid
NM201042060Medicaid
NM201042060OtherPRESBYTERIAN COMMERCIAL
NMG002OtherTRIWEST
TX87381ZOtherHMO BLUE
TX8A8834Medicare ID - Type Unspecified
TX101169101Medicaid
TX159122402Medicaid
OK200014280AMedicaid
TX101169100OtherFIRSTCARE COMMERCIAL
TXP00032823Medicare ID - Type UnspecifiedRAILROAD
TX8G0353OtherBC/BS