Provider Demographics
NPI:1558446187
Name:SAN JUAN ONCOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:SAN JUAN ONCOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEIDHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-564-6850
Mailing Address - Street 1:2325 E 30TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8900
Mailing Address - Country:US
Mailing Address - Phone:505-564-6850
Mailing Address - Fax:505-564-6890
Practice Address - Street 1:2325 E 30TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8900
Practice Address - Country:US
Practice Address - Phone:505-564-6850
Practice Address - Fax:505-564-6890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPROVP23839OtherCIMMARON SALUD MOLINA
CO30179882Medicaid
AZ788664Medicaid
NM020403599OtherENERGY EMPLOYEES OCCU
NM700521049OtherMEDICARE TRAILBLAZERS
NM700521049OtherMEDICARE TRAILBLAZERS
NMCK5339Medicare PIN
NMPROVP23839OtherCIMMARON SALUD MOLINA
CO30179882Medicaid
NM700521049Medicare PIN