Provider Demographics
NPI:1912985946
Name:BLISS, RONALD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:BLISS
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 1:2300 E 30TH ST
Mailing Address - Street 2:BLDG B, STE 102
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-324-1000
Mailing Address - Fax:505-324-1199
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG B, STE 102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-324-1000
Practice Address - Fax:505-324-1199
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000-145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM62965Medicaid
NMNM004266OtherBLUE CROSS
80156045OtherRAILROAD RETIREMENT
NM20592OtherLOVELACE
NJ57647OtherPRESBYTERIAN SALUD
NMNM004266OtherBLUE CROSS