Provider Demographics
NPI:1114089000
Name:NEIDHARDT, EDWARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:NEIDHARDT
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 1:103 S SAINT FRANCIS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2458
Mailing Address - Country:US
Mailing Address - Phone:505-988-5667
Mailing Address - Fax:505-820-1632
Practice Address - Street 1:103 S SAINT FRANCIS DR
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2458
Practice Address - Country:US
Practice Address - Phone:505-988-5667
Practice Address - Fax:505-820-1632
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM892672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NM41814Medicaid
NMHSZ196OtherMEDICARE PART B
NM41814Medicaid