Provider Demographics
NPI:1407846850
Name:BISHOP, JAY R (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:R
Last Name:BISHOP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W COUNTRY CLUB RD
Mailing Address - Street 2:SUITE #205
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5205
Mailing Address - Country:US
Mailing Address - Phone:575-622-7593
Mailing Address - Fax:575-622-5538
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE#205
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:575-622-7593
Practice Address - Fax:575-622-5538
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46011208800000X
NMA-1577-10208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI390807236AEOtherUNITY
WI13590OtherDEAN
NMNPI & TIN#OtherBCBS OF NM
WIWI01K8OtherJOHN DEERE
WIP00061174OtherRAILROAD MEDICARE
WI43509400Medicaid
NM00040021Medicaid
WI46011OtherTOUCHPOINT
NMNPI & TIN#OtherBCBS OF NM
WI390807236AEOtherUNITY
F43398Medicare UPIN
WI43509400Medicaid