Healthcare Provider Details

I. General information

NPI: 1124382056
Provider Name (Legal Business Name): CHRISTINE ISABEL CLAVELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 THE 25 WAY NE STE 325
ALBUQUERQUE NM
87109-5853
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-4411
  • Fax: 505-343-6085
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD2017-0899
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD2017-0899
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: