Healthcare Provider Details

I. General information

NPI: 1598898363
Provider Name (Legal Business Name): PAUL RICHARD SWOBODA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 MONTGOMERY BLVD., NE MONTGOMERY EAST FAMILY MEDICINE
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

PO BOX 26028 CLINICIAN SERVICES / CREDENTIALING
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-275-4288
  • Fax: 505-275-4203
Mailing address:
  • Phone: 505-262-7963
  • Fax: 505-232-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number356087-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number79259
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2019-0734
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: