Healthcare Provider Details

I. General information

NPI: 1366464851
Provider Name (Legal Business Name): NEW MEXICO COLON & RECTAL SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

IV. Provider business mailing address

3810 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-3514
  • Fax: 505-243-3451
Mailing address:
  • Phone: 505-243-3514
  • Fax: 505-243-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CALVIN DUDLEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-243-3514