Provider Demographics
NPI:1942272208
Name:MEZOFF, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MEZOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:2111 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5600
Practice Address - Country:US
Practice Address - Phone:505-863-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM80-682080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10002105OtherLOVELACE HEALTH/SALUD
NMPROVP14495OtherMOLINA
AZ239922Medicaid
NMNM001861OtherBCBS
NM13656Medicaid
85031326887301A131OtherCHAMPUS
NMNM001861OtherBCBS