Provider Demographics
NPI:1326230939
Name:TAOS MOUNTAIN RADIOLOGY INC
Entity Type:Organization
Organization Name:TAOS MOUNTAIN RADIOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EATON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-758-8883
Mailing Address - Street 1:12687 W CEDAR DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2010
Mailing Address - Country:US
Mailing Address - Phone:303-468-1395
Mailing Address - Fax:303-468-1394
Practice Address - Street 1:1397 WEIMER RD
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6284
Practice Address - Country:US
Practice Address - Phone:505-758-8883
Practice Address - Fax:505-751-7661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2002-03042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI03894Medicare UPIN