Provider Demographics
NPI:1902990377
Name:EMERY, MICHAEL R (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:EMERY
Suffix:
Gender:M
Credentials:DO
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 279
Mailing Address - Street 2:
Mailing Address - City:JEMEZ PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87024-0279
Mailing Address - Country:US
Mailing Address - Phone:575-834-7413
Mailing Address - Fax:575-834-7517
Practice Address - Street 1:110 SHEEP SPRINGS WAY
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024-0279
Practice Address - Country:US
Practice Address - Phone:575-834-7413
Practice Address - Fax:575-834-7517
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-112699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z9435Medicaid
G69920Medicare UPIN
342419801Medicare PIN