Healthcare Provider Details

I. General information

NPI: 1215997358
Provider Name (Legal Business Name): M EILEEN MADRID M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 MANZANARES ST
LAS VEGAS NM
87701-3882
US

IV. Provider business mailing address

419 MANZANARES ST
LAS VEGAS NM
87701-3882
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-6773
  • Fax: 505-426-9238
Mailing address:
  • Phone: 505-425-6773
  • Fax: 505-426-9238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number81-79
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: