Provider Demographics
NPI:1326145707
Name:POJOAQUE FAMILY PRACTICE, P.A.
Entity Type:Organization
Organization Name:POJOAQUE FAMILY PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MAESTAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-455-2842
Mailing Address - Street 1:11 W GUTIERREZ UNIT 3810
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-0228
Mailing Address - Country:US
Mailing Address - Phone:505-455-2842
Mailing Address - Fax:505-455-2941
Practice Address - Street 1:5 PETROGLYPH CIR
Practice Address - Street 2:STE. B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-1001
Practice Address - Country:US
Practice Address - Phone:505-455-2842
Practice Address - Fax:505-455-2941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM000261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07930Medicaid
NM700521022Medicare PIN
NMC97949Medicare UPIN