Provider Demographics
NPI:1124350111
Name:ZELICOFF, ALAN (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:ZELICOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 CARLISLE BLVD NE
Mailing Address - Street 2:STE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4829
Mailing Address - Country:US
Mailing Address - Phone:505-888-1075
Mailing Address - Fax:505-888-1082
Practice Address - Street 1:4316 CARLISLE BLVD NE
Practice Address - Street 2:STE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4829
Practice Address - Country:US
Practice Address - Phone:505-888-1075
Practice Address - Fax:505-888-1082
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM81-348207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1043376346OtherGROUP NPI
NM53234774Medicaid
NM53234774Medicaid
300521144Medicare Oscar/Certification