1942435474 NPI number — DR. MIA KRISTEN LOZADA MD

Table of content: DR. MIA KRISTEN LOZADA MD (NPI 1942435474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942435474 NPI number — DR. MIA KRISTEN LOZADA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOZADA
Provider First Name:
MIA
Provider Middle Name:
KRISTEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942435474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLUP
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87305-1337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-722-1000
Provider Business Mailing Address Fax Number:
505-726-8557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 E. NIZHONI BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLUP
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87301-1337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-722-1000
Provider Business Practice Location Address Fax Number:
505-726-8557
Provider Enumeration Date:
05/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A111814 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 83952314 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 730176 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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