Healthcare Provider Details

I. General information

NPI: 1881879005
Provider Name (Legal Business Name): JASON E. MUDD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 TIJERAS AVE NE STE 22
ALBUQUERQUE NM
87106-4749
US

IV. Provider business mailing address

1020 TIJERAS AVE NE STE 22
ALBUQUERQUE NM
87106-4749
US

V. Phone/Fax

Practice location:
  • Phone: 505-848-3124
  • Fax:
Mailing address:
  • Phone: 505-848-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD2011-0142
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: