Provider Demographics
NPI:1194900340
Name:ROESSEL, MARY HASBAH (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:HASBAH
Last Name:ROESSEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S SAINT FRANCIS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2458
Mailing Address - Country:US
Mailing Address - Phone:505-988-5667
Mailing Address - Fax:505-820-1632
Practice Address - Street 1:103 S SAINT FRANCIS DR
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2458
Practice Address - Country:US
Practice Address - Phone:505-988-5667
Practice Address - Fax:505-820-1632
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89-2882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1992782650Medicaid
NM1992782650Medicaid
NM1992782650Medicare NSC
NM1992782650Medicare PIN
NM1992782650Medicare UPIN