Healthcare Provider Details

I. General information

NPI: 1609405315
Provider Name (Legal Business Name): CARL T WHALEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 07/25/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-1654
US

IV. Provider business mailing address

3121 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-1654
US

V. Phone/Fax

Practice location:
  • Phone: 505-228-2108
  • Fax: 505-205-1514
Mailing address:
  • Phone: 505-916-6544
  • Fax: 505-205-1514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberDO2024-0096
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: