Provider Demographics
NPI:1336322312
Name:MORENO- CAMPOS, MARTHA A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:A
Last Name:MORENO- CAMPOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARTHA
Other - Middle Name:A
Other - Last Name:MORENO-CAMPOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1010 BRIDGE BLVD SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-3765
Mailing Address - Country:US
Mailing Address - Phone:505-508-1739
Mailing Address - Fax:
Practice Address - Street 1:1010 BRIDGE BLVD SW
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3765
Practice Address - Country:US
Practice Address - Phone:505-508-1739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K6956Medicaid
357569806OtherMEDICARE
NM98-122OtherSTATE LIC#
NM000K6956Medicaid