Provider Demographics
NPI:1609055102
Name:NORTHERN NEW MEXICO PODIATRY ASSOC.
Entity Type:Organization
Organization Name:NORTHERN NEW MEXICO PODIATRY ASSOC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:505-983-7393
Mailing Address - Street 1:665 HARKLE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4751
Mailing Address - Country:US
Mailing Address - Phone:505-983-7393
Mailing Address - Fax:
Practice Address - Street 1:665 HARKLE RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4751
Practice Address - Country:US
Practice Address - Phone:505-983-7393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM178213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54346Medicaid
NM=========Medicare PIN
1146050001Medicare NSC