Healthcare Provider Details

I. General information

NPI: 1710071196
Provider Name (Legal Business Name): KEVIN GOODLUCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MONTGOMERY BLVD NE BLDG B, STE 100
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 91224
ALBUQUERQUE NM
87199-1224
US

V. Phone/Fax

Practice location:
  • Phone: 505-924-5840
  • Fax: 505-924-5841
Mailing address:
  • Phone: 505-924-5840
  • Fax: 505-924-5841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number97-251
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: