Provider Demographics
NPI:1225194608
Name:RIO GRANDE FOOT CLINIC INC
Entity Type:Organization
Organization Name:RIO GRANDE FOOT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:575-523-8566
Mailing Address - Street 1:710 S ALAMEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2928
Mailing Address - Country:US
Mailing Address - Phone:575-523-8566
Mailing Address - Fax:575-525-2065
Practice Address - Street 1:710 S ALAMEDA BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2928
Practice Address - Country:US
Practice Address - Phone:575-523-8566
Practice Address - Fax:575-525-2065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM142213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54072Medicaid
NMNM035303OtherBLUE CROSS BLUE SHIELD
NMNM035303OtherBLUE CROSS BLUE SHIELD
NM500521076Medicare PIN