Provider Demographics
NPI:1952491086
Name:BOSQUEZ, MATEO G (MD)
Entity Type:Individual
Prefix:
First Name:MATEO
Middle Name:G
Last Name:BOSQUEZ
Suffix:
Gender:M
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:PO BOX 27829
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125
Mailing Address - Country:US
Mailing Address - Phone:505-232-1920
Mailing Address - Fax:505-727-9276
Practice Address - Street 1:2929 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:505-839-2300
Practice Address - Fax:505-839-2303
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74123208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91926262Medicaid
NMNM301355Medicare PIN
B21401Medicare UPIN
NM348513001Medicare ID - Type Unspecified