Provider Demographics
NPI:1376520601
Name:BACA, MARSHALL G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:G
Last Name:BACA
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 1:2411 OSBORNE RD
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3265
Mailing Address - Country:US
Mailing Address - Phone:505-885-2188
Mailing Address - Fax:505-885-6486
Practice Address - Street 1:2411 OSBORNE RD
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3265
Practice Address - Country:US
Practice Address - Phone:505-885-2188
Practice Address - Fax:505-885-6486
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM965174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH5181Medicaid
NMF13673Medicare UPIN