Provider Demographics
NPI:1164484002
Name:O'ROURKE, AIDEN MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:AIDEN
Middle Name:MATTHEW
Last Name:O'ROURKE
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 1:1399 WEIMER RD
Mailing Address - Street 2:# 600
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6340
Mailing Address - Country:US
Mailing Address - Phone:575-751-0334
Mailing Address - Fax:575-751-0297
Practice Address - Street 1:1399 WEIMER RD
Practice Address - Street 2:# 600
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6340
Practice Address - Country:US
Practice Address - Phone:575-751-0334
Practice Address - Fax:575-751-0297
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0822208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67251382Medicaid
NM67251382Medicaid
FLD27808Medicare UPIN