Provider Demographics
NPI:1912915307
Name:BAMBERG, RAYMOND E (BC-HIS)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:E
Last Name:BAMBERG
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 N TELSHOR BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8244
Mailing Address - Country:US
Mailing Address - Phone:505-523-8816
Mailing Address - Fax:505-522-0026
Practice Address - Street 1:920 N TELSHOR BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8244
Practice Address - Country:US
Practice Address - Phone:505-523-8816
Practice Address - Fax:505-522-0026
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM290237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1912915307OtherBLUE CROSS BLUE SHIELD
NMT9313Medicaid