Provider Demographics
NPI:1457789125
Name:GREG BACA MD, LLC
Entity Type:Organization
Organization Name:GREG BACA MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-795-5217
Mailing Address - Street 1:112 GRAND CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3423
Mailing Address - Country:US
Mailing Address - Phone:505-795-5217
Mailing Address - Fax:
Practice Address - Street 1:464 CENTRAL AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3350
Practice Address - Country:US
Practice Address - Phone:505-795-5217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-05532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13252291Medicaid