Healthcare Provider Details

I. General information

NPI: 1790738565
Provider Name (Legal Business Name): WARREN DOUGLAS MCKELVY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W. COUNTRY CLUB RD
ROSWELL NM
88201
US

IV. Provider business mailing address

313 W. COUNTRY CLUB RD
ROSWELL NM
88201
US

V. Phone/Fax

Practice location:
  • Phone: 575-625-1371
  • Fax: 575-625-1490
Mailing address:
  • Phone: 575-625-1371
  • Fax: 575-625-1490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number77-217
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: