Individual
MR. TIMOTHY J VANDERJAGT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
455 SAINT MICHAELS DR, SANTA FE, NM 87505-7601
(505) 820-5274
Mailing address
465 SAINT MICHAELS DR, SUITE 115, SANTA FE, NM 87505-7670
(505) 986-8620
(505) 820-2461
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
MD2007-0397
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
21079021
—
NM
01
—
NM001G14
BCBS OF NM
NM
Enumeration date
08/15/2007
Last updated
05/09/2008
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