Provider Demographics
NPI:1124809066
Name:SANDROCK PODIATRY LLC
Entity type:Organization
Organization Name:SANDROCK PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HAAG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-787-9035
Mailing Address - Street 1:4707 RIO ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5323
Mailing Address - Country:US
Mailing Address - Phone:505-787-9003
Mailing Address - Fax:505-291-3293
Practice Address - Street 1:4707 RIO ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5323
Practice Address - Country:US
Practice Address - Phone:505-787-9035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-06
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6N8581OtherNM-GROUP MEDICARE PTAN
NM74122355Medicaid