Provider Demographics
NPI:1760438196
Name:ANDAZOLA, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ANDAZOLA
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 6159
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006-6159
Mailing Address - Country:US
Mailing Address - Phone:575-521-5370
Mailing Address - Fax:575-521-5376
Practice Address - Street 1:2450 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5069
Practice Address - Country:US
Practice Address - Phone:575-521-5370
Practice Address - Fax:575-521-5376
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM99-154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP00699013OtherRR MEDICARE
NM15463357Medicaid
NM15463357Medicaid
H4229Medicare UPIN