Healthcare Provider Details

I. General information

NPI: 1780605923
Provider Name (Legal Business Name): DAVID BENNAHUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WESTSIDE FAMILY / SENIOR HEALTH CENTER 4808 MC MAHON BLVD.
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

4808 MCMAHON BLVD NW MSC10 5550
ALBUQUERQUE NM
87114-5010
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1754
  • Fax:
Mailing address:
  • Phone: 505-272-1754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number70-13
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: