Provider Demographics
NPI:1558455923
Name:EGLI, DOUGLAS R (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:EGLI
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 1:490B W ZIA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7008
Mailing Address - Country:US
Mailing Address - Phone:505-913-3820
Mailing Address - Fax:505-913-3829
Practice Address - Street 1:490B W ZIA RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7008
Practice Address - Country:US
Practice Address - Phone:505-913-3820
Practice Address - Fax:505-913-3829
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55049Medicaid
G63270Medicare UPIN