Healthcare Provider Details

I. General information

NPI: 1619172848
Provider Name (Legal Business Name): CLYDE KENNEDY MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 HWY 187
HATCH NM
87937-0370
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937-0370
US

V. Phone/Fax

Practice location:
  • Phone: 505-267-3286
  • Fax: 505-267-1747
Mailing address:
  • Phone: 505-267-3286
  • Fax: 505-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2007-0136
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: