Provider Demographics
NPI:1760657035
Name:STEPHEN D CETRULO MD
Entity Type:Organization
Organization Name:STEPHEN D CETRULO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:R
Authorized Official - Last Name:COCKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-751-0334
Mailing Address - Street 1:1399 WEIMER RD
Mailing Address - Street 2:SUITE # 600
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6340
Mailing Address - Country:US
Mailing Address - Phone:575-751-0334
Mailing Address - Fax:575-751-0297
Practice Address - Street 1:1399 WEIMER RD
Practice Address - Street 2:SUITE # 600
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6340
Practice Address - Country:US
Practice Address - Phone:575-751-0334
Practice Address - Fax:575-751-0297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM05108Medicaid
NM=========Medicare PIN