Provider Demographics
NPI:1720089519
Name:INDACOCHEA, FERNANDO J (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:J
Last Name:INDACOCHEA
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 1:4395 ISLETA CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4297
Mailing Address - Country:US
Mailing Address - Phone:304-902-0443
Mailing Address - Fax:
Practice Address - Street 1:4401 E. LOHMAN AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-532-9077
Practice Address - Fax:575-532-9221
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0107734000Medicaid
H33157Medicare UPIN
IN7283821Medicare ID - Type UnspecifiedMEDICARE