Provider Demographics
NPI:1700197001
Name:LAS CRUCES FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:LAS CRUCES FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-532-1111
Mailing Address - Street 1:2930 HILLRISE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4776
Mailing Address - Country:US
Mailing Address - Phone:575-532-1111
Mailing Address - Fax:575-532-1122
Practice Address - Street 1:2930 HILLRISE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4776
Practice Address - Country:US
Practice Address - Phone:575-532-1111
Practice Address - Fax:575-532-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2010-0103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53376081Medicaid