Provider Demographics
NPI:1366469314
Name:CARLOS J ESPARZA MD PC
Entity Type:Organization
Organization Name:CARLOS J ESPARZA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMIN OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-938-1517
Mailing Address - Street 1:3846 MASTHEAD ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4479
Mailing Address - Country:US
Mailing Address - Phone:505-242-1711
Mailing Address - Fax:505-242-0189
Practice Address - Street 1:3846 MASTHEAD ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4479
Practice Address - Country:US
Practice Address - Phone:505-242-1711
Practice Address - Fax:505-242-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97227208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q28004Medicaid
G36683Medicare UPIN
NM000Q28004Medicaid
400521125Medicare PIN