Basic Information
| Provider Information | |||||||||
| NPI: | 1538555461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGUERO BLAU | ||||||||
| FirstName: | ROBERTO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 N POPE ST | ||||||||
| Address2: | |||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880615161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8883686983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 N POPE ST | ||||||||
| Address2: | |||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880615161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753881511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2015 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RS2015-0330 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | MD2019-1096 | NM | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | MD2019-1096 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD2019-1096 | 01 | NM | NM MEDICAL BOARD | OTHER |