Provider Demographics
NPI:1104817782
Name:STOLTZFUS, ERIC W (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:W
Last Name:STOLTZFUS
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 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:555 S SCHWARTZ AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5955
Practice Address - Country:US
Practice Address - Phone:505-609-6680
Practice Address - Fax:505-325-1722
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM953552084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ8236Medicaid
8HZD04Medicare PIN
8HZE15Medicare PIN
G32743Medicare UPIN
NMJ8236Medicaid