Provider Demographics
NPI:1528057460
Name:BEAR, RUTH (LD)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:BEAR
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 VISTA LARGA CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2646
Mailing Address - Country:US
Mailing Address - Phone:505-265-7172
Mailing Address - Fax:
Practice Address - Street 1:1650 UNIVERSITY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1734
Practice Address - Country:US
Practice Address - Phone:505-272-8062
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM027133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89531558Medicaid