Provider Demographics
NPI:1194718072
Name:PATTILLO, ROBERT J
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:PATTILLO
Suffix:
Gender:M
Credentials:
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 2860
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-2860
Mailing Address - Country:US
Mailing Address - Phone:575-439-1397
Mailing Address - Fax:
Practice Address - Street 1:2351 INDIAN WELLS
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5012
Practice Address - Country:US
Practice Address - Phone:575-439-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM827225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00Q162OtherBLUE CROSS BLUE SHIELD
NM79263Medicaid