Provider Demographics
NPI:1235263898
Name:RONALD J ESCUDERO MD PC
Entity Type:Organization
Organization Name:RONALD J ESCUDERO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ESCUDERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-855-5500
Mailing Address - Street 1:4100 WOLCOTT AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4572
Mailing Address - Country:US
Mailing Address - Phone:505-855-5500
Mailing Address - Fax:505-855-5501
Practice Address - Street 1:4100 WOLCOTT AVE NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4572
Practice Address - Country:US
Practice Address - Phone:505-855-5500
Practice Address - Fax:505-855-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-196174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42085Medicaid
NME82564Medicare UPIN