Basic Information
| Provider Information | |||||||||
| NPI: | 1700923075 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COE | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 DEMOSS STREET | ||||||||
| Address2: | HIDALGO MEDICAL SERVICES INC | ||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 800452632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755428384 | ||||||||
| FaxNumber: | 5755428367 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 WEST 11TH STREET | ||||||||
| Address2: | HMS MED SQUARE CLINIC | ||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753881511 | ||||||||
| FaxNumber: | 5753883465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 11/10/2008 | ||||||||
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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 | 2084P0800X | MD2008-0173 | NM | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 68381867 | 05 | NM | MEDICAID |