Provider Demographics
NPI:1972620557
Name:WILBUR A TSO MD PC
Entity Type:Organization
Organization Name:WILBUR A TSO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:TSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-327-9876
Mailing Address - Street 1:211 N AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8411
Mailing Address - Country:US
Mailing Address - Phone:505-327-9876
Mailing Address - Fax:505-326-6650
Practice Address - Street 1:211 N AUBURN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8411
Practice Address - Country:US
Practice Address - Phone:505-327-9876
Practice Address - Fax:505-326-6650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM600522369OtherMEDICARE PTAN
NM09811Medicaid