Healthcare Provider Details

I. General information

NPI: 1962682195
Provider Name (Legal Business Name): MEDICAL ARTS DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ENCINO PL NE STE E6
ALBUQUERQUE NM
87102-2645
US

IV. Provider business mailing address

801 ENCINO PL NE STE E6
ALBUQ NM
87102-2645
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-4414
  • Fax: 505-299-4513
Mailing address:
  • Phone: 505-299-4414
  • Fax: 505-299-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6534
License Number StateNM

VIII. Authorized Official

Name: DONALD D. HARVILLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-299-4414