Healthcare Provider Details

I. General information

NPI: 1669668497
Provider Name (Legal Business Name): MONTHIDA FANGTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DOIM RHEUMATOLOGY 1 UNIVERSITY OF NEW MEXICO MSC 10-5550
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4761
  • Fax: 505-272-3624
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD451462
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD2015-0730
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: