Provider Demographics
NPI:1922113349
Name:MCCORMICK, ROBERT ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALEXANDER
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:ALEXANDER
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,LTD
Mailing Address - Street 1:11 CALLE MEDICO
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4705
Mailing Address - Country:US
Mailing Address - Phone:505-983-1003
Mailing Address - Fax:505-983-1008
Practice Address - Street 1:11 CALLE MEDICO
Practice Address - Street 2:SUITE 2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4705
Practice Address - Country:US
Practice Address - Phone:505-983-1003
Practice Address - Fax:505-983-1008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM69-164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18135Medicaid
NM18135Medicaid
NH2104391HMedicare PIN