Basic Information
| Provider Information | |||||||||
| NPI: | 1962467555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UNDERWOOD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RANDALL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2669 SCENIC DR | ||||||||
| Address2: | |||||||||
| City: | ALAMOGORDO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883108700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754340159 | ||||||||
| FaxNumber: | 8886876133 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PENNSYLVANIA AVE STE 570 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882014792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754340159 | ||||||||
| FaxNumber: | 8886876133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | MD2019-0235 | NM | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 78176565 | 05 | NM | MEDICAID |