Provider Demographics
NPI:1659413391
Name:EICHWALD, RAYMOND
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:EICHWALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 MADISON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3012
Mailing Address - Country:US
Mailing Address - Phone:505-884-6940
Mailing Address - Fax:
Practice Address - Street 1:6312 HWY 550
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NM
Practice Address - Zip Code:87013
Practice Address - Country:US
Practice Address - Phone:505-289-0148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP9936Medicaid