Provider Demographics
NPI:1548238231
Name:THATCH, LEONARD IRWIN (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:IRWIN
Last Name:THATCH
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 1:2055 S PACHECO ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3997
Mailing Address - Country:US
Mailing Address - Phone:505-473-0390
Mailing Address - Fax:505-473-0375
Practice Address - Street 1:2055 S PACHECO ST
Practice Address - Street 2:SUITE 600
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3997
Practice Address - Country:US
Practice Address - Phone:505-473-0390
Practice Address - Fax:505-473-0375
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2003-0709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A75310Medicare UPIN