Provider Demographics
NPI:1831463918
Name:MOSAIC NEUROSCIENCE GROUP
Entity Type:Organization
Organization Name:MOSAIC NEUROSCIENCE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-430-4746
Mailing Address - Street 1:1700 N UNION AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3267
Mailing Address - Country:US
Mailing Address - Phone:602-430-4746
Mailing Address - Fax:
Practice Address - Street 1:1700 N UNION AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3267
Practice Address - Country:US
Practice Address - Phone:602-430-4746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0490207R00000X
NM2008-05952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty