Healthcare Provider Details

I. General information

NPI: 1235377268
Provider Name (Legal Business Name): BEVERLY A. PUCKA, MD P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8120 CONSTITUTION PL NE SUITE 220
ALBUQUERQUE NM
87110-7654
US

IV. Provider business mailing address

8120 CONSTITUTION PL NE SUITE 220
ALBUQUERQUE NM
87110-7654
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8741
  • Fax: 505-842-8190
Mailing address:
  • Phone: 505-842-8741
  • Fax: 505-842-8190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number86-107
License Number StateNM

VIII. Authorized Official

Name: BEVERLY A PUCKA
Title or Position: OWNER
Credential: M.D.
Phone: 505-842-8741