Basic Information
| Provider Information | |||||||||
| NPI: | 1245248814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIEGO | ||||||||
| FirstName: | RUBEN | ||||||||
| MiddleName: | RAUL | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GRIEGO | ||||||||
| OtherFirstName: | RUBEN | ||||||||
| OtherMiddleName: | RAUL | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10489 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871840489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627026 | ||||||||
| FaxNumber: | 5057279276 | ||||||||
| Practice Location | |||||||||
| Address1: | 5150 JOURNAL CENTER BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052623233 | ||||||||
| FaxNumber: | 5052623191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 87241 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 39891 | 05 | NM | MEDICAID |