Provider Demographics
NPI:1639285208
Name:RANEY, JEREMIAH KENT (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:KENT
Last Name:RANEY
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 1:2402 W PIERCE ST
Mailing Address - Street 2:STE 3C
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3537
Mailing Address - Country:US
Mailing Address - Phone:575-887-0530
Mailing Address - Fax:575-885-6309
Practice Address - Street 1:2402 W PIERCE ST
Practice Address - Street 2:STE 3C
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3537
Practice Address - Country:US
Practice Address - Phone:575-887-0530
Practice Address - Fax:575-885-6309
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-111208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25940Medicaid
NM25940Medicaid