Basic Information
| Provider Information | |||||||||
| NPI: | 1629349576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | JABEZ | ||||||||
| MiddleName: | BABU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 SARA RD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871241025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052537900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2012 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0146391 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 207Q00000X | 1629349576 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2021-0456 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1629349576 | 01 | NPI | OTHER |