Provider Demographics
NPI:1306830450
Name:SAN MIGUEL CLINIC CORP DBA NORTHERN NEW MEXICO UROLOGY
Entity Type:Organization
Organization Name:SAN MIGUEL CLINIC CORP DBA NORTHERN NEW MEXICO UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:UROLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:AKHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-454-4000
Mailing Address - Street 1:2301 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4966
Mailing Address - Country:US
Mailing Address - Phone:505-454-4000
Mailing Address - Fax:505-454-4004
Practice Address - Street 1:2301 7TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4966
Practice Address - Country:US
Practice Address - Phone:505-454-4000
Practice Address - Fax:505-454-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000173208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09426531Medicaid
NMG18450Medicare UPIN