Healthcare Provider Details

I. General information

NPI: 1598737587
Provider Name (Legal Business Name): BRADEN RANDALL HALE MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO # 105550
ALBUQUERQUE NM
87131-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR NMCSD, ATTN: MEDICAL STAFF SERVICES
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5666
  • Fax: 505-272-4435
Mailing address:
  • Phone: 619-532-6460
  • Fax: 619-532-6299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberG79430
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD2020-0838
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: