Provider Demographics
NPI:1174151914
Name:TSOSIE, DATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:DATHAN
Middle Name:
Last Name:TSOSIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3338
Mailing Address - Street 2:
Mailing Address - City:CANONCITO
Mailing Address - State:NM
Mailing Address - Zip Code:87026-3338
Mailing Address - Country:US
Mailing Address - Phone:505-908-2571
Mailing Address - Fax:505-908-2310
Practice Address - Street 1:129 MEDICINE HORSE DRIVE
Practice Address - Street 2:
Practice Address - City:TO'HAJIILEE
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2571
Practice Address - Fax:505-908-2310
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-1471207Q00000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine