Provider Demographics
NPI:1710965272
Name:AGODON, CARMELITA (MD)
Entity Type:Individual
Prefix:
First Name:CARMELITA
Middle Name:
Last Name:AGODON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:1901 REDROCK DR
Practice Address - Street 2:REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5683
Practice Address - Country:US
Practice Address - Phone:505-863-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-01207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10004799OtherLOVELACE HEALTH/SALUD
P00200853OtherRAILROAD MEDICARE
AZ768781OtherAHCCCS
NMNM009E83OtherBC/BS
85031326887301A159OtherCHAMPUS
NMPROVP11034OtherMOLINA
NM48126705Medicaid
P00211389OtherRAILROAD MEDICARE
85031326887301A159OtherCHAMPUS