Healthcare Provider Details

I. General information

NPI: 1760441018
Provider Name (Legal Business Name): MICHAEL DAVID MULDAWER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 EUBANK BLVD NE #9
ALBUQUERQUE NM
87111-3465
US

IV. Provider business mailing address

3900 EUBANK BLVD. NE #9
ALBUQUERQUE NM
87111-0000
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-4040
  • Fax:
Mailing address:
  • Phone: 505-294-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number70-173
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: