Provider Demographics
NPI:1417946195
Name:LA FATA, SALVATORE (MD)
Entity Type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:
Last Name:LA FATA
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 1:2020 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4940
Mailing Address - Country:US
Mailing Address - Phone:505-762-4507
Mailing Address - Fax:505-762-7220
Practice Address - Street 1:2020 SHEFFIELD DR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4940
Practice Address - Country:US
Practice Address - Phone:505-762-4507
Practice Address - Fax:505-762-7220
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75-62208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15651Medicaid
NM1570OtherBLUE CROSS & BLUE SHIELD