Provider Demographics
NPI:1366439978
Name:RAES, DANIEL E (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:RAES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:C/O MSO ADMINISTRATION
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-624-4777
Mailing Address - Fax:
Practice Address - Street 1:300 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE# 220
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5202
Practice Address - Country:US
Practice Address - Phone:505-625-1292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30722Medicaid
NMNPI#OtherBCBS OF NM
NMG00877Medicare UPIN
NM343401902Medicare PIN