Provider Demographics
NPI:1104378314
Name:DESERT MOUNTAIN SKIN CANCER SURGERY, LLC
Entity Type:Organization
Organization Name:DESERT MOUNTAIN SKIN CANCER SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:REISINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-980-8738
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-0604
Mailing Address - Country:US
Mailing Address - Phone:505-980-8738
Mailing Address - Fax:
Practice Address - Street 1:2019 GALISTEO STREET
Practice Address - Street 2:SUITE N-9B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-980-8738
Practice Address - Fax:505-404-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0829207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1003975699Medicaid
NM1003975699Medicaid
NM1003975699Medicare UPIN