Healthcare Provider Details

I. General information

NPI: 1184980989
Provider Name (Legal Business Name): PAUL ALLEN BRITTAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DR MARTIN LUTHER KING JR AVE NE STE 102
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

715 DR MARTIN LUTHER KING JR AVE NE STE 102
ALBUQUERQUE NM
87102-3666
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-3040
  • Fax: 505-727-9590
Mailing address:
  • Phone: 505-727-3040
  • Fax: 505-727-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberPENDING
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD2018-0545
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: