Provider Demographics
NPI:1962901090
Name:HIGH DESERT FOOT & ANKLE SPECIALISTS, LLC
Entity type:Organization
Organization Name:HIGH DESERT FOOT & ANKLE SPECIALISTS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:505-565-1155
Mailing Address - Street 1:PO BOX 53056
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87153-3056
Mailing Address - Country:US
Mailing Address - Phone:505-565-1155
Mailing Address - Fax:505-565-1166
Practice Address - Street 1:9412 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2878
Practice Address - Country:US
Practice Address - Phone:505-565-1155
Practice Address - Fax:505-565-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM279213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84001780Medicaid
NM55003800Medicaid