Provider Demographics
NPI:1578738381
Name:ALDEN G COCKBURN MD
Entity Type:Organization
Organization Name:ALDEN G COCKBURN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:R
Authorized Official - Last Name:COCKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-751-0334
Mailing Address - Street 1:1399 WEIMER RD
Mailing Address - Street 2:# 600
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6340
Mailing Address - Country:US
Mailing Address - Phone:575-751-0334
Mailing Address - Fax:575-751-0297
Practice Address - Street 1:1399 WEIMER RD
Practice Address - Street 2:# 600
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6340
Practice Address - Country:US
Practice Address - Phone:575-751-0334
Practice Address - Fax:575-751-0297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20040101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29805325Medicaid
NM29805325Medicaid