Healthcare Provider Details

I. General information

NPI: 1588066138
Provider Name (Legal Business Name): HIGH DESERT DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12241 ACADEMY RD NE STE 204
ALBUQUERQUE NM
87111-8051
US

IV. Provider business mailing address

12241 ACADEMY RD NE STE 204
ALBUQUERQUE NM
87111-8051
US

V. Phone/Fax

Practice location:
  • Phone: 505-938-4214
  • Fax:
Mailing address:
  • Phone: 505-938-4214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNM

VIII. Authorized Official

Name: JOHN DAVID CAREY
Title or Position: OWNER/MD
Credential: M.D.
Phone: 505-938-4214