Healthcare Provider Details

I. General information

NPI: 1952306219
Provider Name (Legal Business Name): PAUL A ANTHONY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 JEFFERSON LN NE
ALBUQUERQUE NM
87109-2127
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 505-889-9639
  • Fax: 505-889-2978
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number01077206A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01077206A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number86-165
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: