Healthcare Provider Details

I. General information

NPI: 1770789125
Provider Name (Legal Business Name): MARTIN JON KILEEN M.D.,M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTA ANA CLINIC O2-C DOVE RD
BERNALILLO NM
87004
US

IV. Provider business mailing address

1 SAGEBRUSH ST. ISLETA HEALTH CENTER
ISLETA NM
87022
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-2497
  • Fax: 505-867-1526
Mailing address:
  • Phone: 505-869-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2014-0014
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6242
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: