Provider Demographics
NPI:1396774204
Name:IRALU, JONATHAN VILASIER (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:VILASIER
Last Name:IRALU
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 1:516 E. NIZHONI BLVD.
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-726-8557
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-726-8557
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000R8847Medicaid
AZ419631Medicaid
TX8HZ058Medicare ID - Type UnspecifiedHSZ005
NM000R8847Medicaid
TX8HZ151Medicare ID - Type UnspecifiedHSZ006
TX8HBW94Medicare ID - Type UnspecifiedHSZ197
TX8HZ07QMedicare ID - Type UnspecifiedHSZ003
TX8HC964Medicare ID - Type UnspecifiedHSZ002
AZ419631Medicaid