Provider Demographics
NPI:1902863640
Name:LITTLEFIELD, JERALD JOSEPH (MD)
Entity Type:Individual
Prefix:MR
First Name:JERALD
Middle Name:JOSEPH
Last Name:LITTLEFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2100 CALLE DE LA VUELTA
Mailing Address - Street 2:E-104
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4819
Mailing Address - Country:US
Mailing Address - Phone:505-982-8831
Mailing Address - Fax:505-983-2763
Practice Address - Street 1:2100 CALLE DE LA VUELTA
Practice Address - Street 2:E-104
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4819
Practice Address - Country:US
Practice Address - Phone:505-982-8831
Practice Address - Fax:505-983-2763
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM92284207W00000X
VA0101026463207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME5705Medicaid
NME5705Medicaid
349228903Medicare PIN