Healthcare Provider Details

I. General information

NPI: 1366530933
Provider Name (Legal Business Name): RICARDO DAVILA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO SE NEW MEXICO VA HEALTH CARE SYSTEM
ALBUQUERQUE NM
87108-5154
US

IV. Provider business mailing address

6601 TENNYSON ST NE APT # 14203
ALBUQUERQUE NM
87111-8161
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-5466
Mailing address:
  • Phone: 520-249-9177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberJ6101
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: