Healthcare Provider Details

I. General information

NPI: 1053327361
Provider Name (Legal Business Name): CLIFFORD R STOLLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 SEAGULL ST NE SUITE 106
ALBUQUERQUE NM
87109-2500
US

IV. Provider business mailing address

6100 SEAGULL ST NE SUITE 106
ALBUQUERQUE NM
87109-2500
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-4395
  • Fax: 505-883-4397
Mailing address:
  • Phone: 505-883-4395
  • Fax: 505-883-4397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number82-316
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: