Provider Demographics
NPI:1801972518
Name:NEIDHART, JEFFREY D (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:NEIDHART
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:PO BOX 1799
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499
Mailing Address - Country:US
Mailing Address - Phone:505-564-6850
Mailing Address - Fax:505-564-6890
Practice Address - Street 1:2325 E 30TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8900
Practice Address - Country:US
Practice Address - Phone:505-564-6850
Practice Address - Fax:505-564-6890
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0176207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM38022222Medicaid
CO93002840Medicaid
NMNM019A39OtherBLUE CROSS OF NEW MEXICO
UTT0445Medicaid
AZ764086Medicaid
NMP00012248Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NM347226803Medicare ID - Type Unspecified
UTT0445Medicaid