Provider Demographics
NPI:1407004583
Name:ACEVEDO GONZALEZ, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ACEVEDO GONZALEZ
Suffix:
Gender:F
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:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0843
Mailing Address - Country:US
Mailing Address - Phone:575-356-6695
Mailing Address - Fax:575-356-5948
Practice Address - Street 1:1515 WEST FIR
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-0843
Practice Address - Country:US
Practice Address - Phone:575-356-6695
Practice Address - Fax:575-356-5948
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27071383Medicaid
NM27071383Medicaid