Healthcare Provider Details

I. General information

NPI: 1063948123
Provider Name (Legal Business Name): PAUL WHITEHOUSE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 ACADEMY RD NE
ALBUQUERQUE NM
87111-1111
US

IV. Provider business mailing address

13627 KEESHA JO AVE SE
ALBUQUERQUE NM
87123-1095
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4164
  • Fax: 505-247-4561
Mailing address:
  • Phone: 813-451-8690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD435
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: