Provider Demographics
NPI:1902818719
Name:CONDER, LORETTA A (MD)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:A
Last Name:CONDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:A
Other - Last Name:ROBERTS-AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-2012
Mailing Address - Country:US
Mailing Address - Phone:505-445-7793
Mailing Address - Fax:505-445-7743
Practice Address - Street 1:203 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2012
Practice Address - Country:US
Practice Address - Phone:505-445-7793
Practice Address - Fax:505-445-7743
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM609536Medicaid
1468942OtherUMWA FUNDS UNITED MINE WO
019763300OtherBLACK LUNG
482966OtherBCBS OF KS
1468942OtherUMWA FUNDS UNITED MINE WO
NM42448Medicaid
1468942OtherUMWA FUNDS UNITED MINE WO