Provider Demographics
NPI:1548268428
Name:BIGELOW, DARYL W (OD)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:W
Last Name:BIGELOW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 HORIZON BLVD NE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1533
Mailing Address - Country:US
Mailing Address - Phone:505-246-2622
Mailing Address - Fax:505-213-0103
Practice Address - Street 1:1740 GRANDE BLVD SE
Practice Address - Street 2:SUITE B
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1799
Practice Address - Country:US
Practice Address - Phone:505-892-3434
Practice Address - Fax:505-891-2402
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM416152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP2065Medicaid
NMP00151438OtherMEDICARE ID
AZ881418Medicaid
NMNM00PA10OtherBC BS OF NM
T01117Medicare UPIN
NM341425503Medicare PIN