Healthcare Provider Details

I. General information

NPI: 1720081839
Provider Name (Legal Business Name): CLARK E HASKINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVENUE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

4901 LANG AVENUE NE
ALBUQUERQUE NM
87109-4397
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8171
  • Fax: 505-246-0684
Mailing address:
  • Phone: 505-842-8171
  • Fax: 505-246-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number81-219
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: