Provider Demographics
NPI:1710971015
Name:VAKSELIS, PAUL A (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:VAKSELIS
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:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-1560
Mailing Address - Country:US
Mailing Address - Phone:505-647-8366
Mailing Address - Fax:505-647-8387
Practice Address - Street 1:2909 HILLRISE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4701
Practice Address - Country:US
Practice Address - Phone:505-522-5888
Practice Address - Fax:505-521-1876
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000120208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM850466870OtherCHAMPUS
NM54770OtherPRESBYTERIAN
NM74423Medicaid
NMNM009426OtherBC/BS
NM31557OtherLOVELACE
NM850460870OtherCIMARRON SALUD
NM020049262OtherRR MEDICARE
NM880110001OtherWPS TRICARE
NM880110001OtherWPS TRICARE
NM850466870OtherCHAMPUS