Basic Information
| Provider Information | |||||||||
| NPI: | 1144603408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | MARCO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882602830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 N MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753966611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2015 | ||||||||
| LastUpdateDate: | 07/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RS2015-0486 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2018-0153 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.