Provider Demographics
NPI:1255531083
Name:MICHAEL R PINCUS DPM LLC
Entity type:Organization
Organization Name:MICHAEL R PINCUS DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PINCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-896-1500
Mailing Address - Street 1:2207 GOLF COURSE RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1954
Mailing Address - Country:US
Mailing Address - Phone:505-896-1500
Mailing Address - Fax:505-896-1113
Practice Address - Street 1:2207 GOLF COURSE RD SE STE A
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1954
Practice Address - Country:US
Practice Address - Phone:505-896-1500
Practice Address - Fax:505-896-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM130213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53355Medicaid
NM0914420001Medicare NSC
NM300521113Medicare PIN