Provider Demographics
NPI:1225135791
Name:COCKBURN, ALDEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:ALDEN
Middle Name:G
Last Name:COCKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1399 WEIMER ROAD
Mailing Address - Street 2:# 600B
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6351
Mailing Address - Country:US
Mailing Address - Phone:505-751-0334
Mailing Address - Fax:505-751-0297
Practice Address - Street 1:1399 WEIMER ROAD
Practice Address - Street 2:# 600B
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6351
Practice Address - Country:US
Practice Address - Phone:505-751-0334
Practice Address - Fax:505-751-0297
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0101208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2004-0101OtherMEDICAL LIC #
NM00NM009M74OtherBLUE CROSS BLUE SHIELD
NM29805325Medicaid
NM29805325Medicaid
NMA66897Medicare UPIN
NM00NM009M74OtherBLUE CROSS BLUE SHIELD