Provider Demographics
NPI:1245763929
Name:IDOC, INC
Entity Type:Organization
Organization Name:IDOC, INC
Other - Org Name:I DOC'S
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:STONEKING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-238-1519
Mailing Address - Street 1:3811 CERRILLOS RD STE 103
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4112
Mailing Address - Country:US
Mailing Address - Phone:505-989-9600
Mailing Address - Fax:505-982-3616
Practice Address - Street 1:3811 CERRILLOS RD STE 103
Practice Address - Street 2:STE 103
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4112
Practice Address - Country:US
Practice Address - Phone:505-989-9600
Practice Address - Fax:505-982-3616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93424817Medicaid