Provider Demographics
NPI:1235372012
Name:LOBE, MAVRICK JAMES (DOM)
Entity Type:Individual
Prefix:DR
First Name:MAVRICK
Middle Name:JAMES
Last Name:LOBE
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 PACHECO ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4222
Mailing Address - Country:US
Mailing Address - Phone:505-577-1588
Mailing Address - Fax:
Practice Address - Street 1:1348 PACHECO ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4222
Practice Address - Country:US
Practice Address - Phone:505-577-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM446RX2208D00000X, 171100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171100000XOther Service ProvidersAcupuncturist
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine