Provider Demographics
NPI:1639386881
Name:AVALOS, MIGUEL ANGEL (ABOC)
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:AVALOS
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3961 E LOHMAN AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8269
Mailing Address - Country:US
Mailing Address - Phone:575-522-6868
Mailing Address - Fax:575-522-6869
Practice Address - Street 1:3961 E LOHMAN AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8269
Practice Address - Country:US
Practice Address - Phone:575-522-6868
Practice Address - Fax:575-522-6869
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM07981156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0775110001Medicare NSC