Provider Demographics
NPI:1790982643
Name:BACA, RANDOLPH P JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:P
Last Name:BACA
Suffix:JR
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 95602
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199
Mailing Address - Country:US
Mailing Address - Phone:505-504-5505
Mailing Address - Fax:505-214-5614
Practice Address - Street 1:1003 LUNA CIR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1973
Practice Address - Country:US
Practice Address - Phone:505-504-5505
Practice Address - Fax:505-214-5614
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAG3361893-B4162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13558242Medicaid
NM13558242Medicaid