Provider Demographics
NPI:1487754735
Name:HIGH DESERT NEUROLOGY
Entity type:Organization
Organization Name:HIGH DESERT NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:505-892-8915
Mailing Address - Street 1:PO BOX 44430
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-4430
Mailing Address - Country:US
Mailing Address - Phone:505-892-8915
Mailing Address - Fax:505-994-3028
Practice Address - Street 1:4131 BARBARA LOOP SE
Practice Address - Street 2:SUITE 1-A
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1362
Practice Address - Country:US
Practice Address - Phone:505-892-8915
Practice Address - Fax:505-994-3028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201047864OtherPHP & SALUD
NM23432Medicaid
NM00NM009T07OtherBCBS
NMC100521093OtherUNITED AMERICAN
NMNM9999OtherMUTUAL OF OMAHA
NMNM9999OtherMUTUAL OF OMAHA
NMNM9999OtherMUTUAL OF OMAHA
NMP00281702Medicare ID - Type UnspecifiedPALMETTO GBA
NM100521093Medicare PIN
NM100521093Medicare ID - Type Unspecified