Healthcare Provider Details

I. General information

NPI: 1013146679
Provider Name (Legal Business Name): MADAD GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2009
Last Update Date: 07/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CERRILLOS RD STE 724C
SANTA FE NM
87507-2690
US

IV. Provider business mailing address

2442 CERRILLOS RD STE 281
SANTA FE NM
87505-3262
US

V. Phone/Fax

Practice location:
  • Phone: 575-628-0926
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD2007-0654
License Number StateNM

VIII. Authorized Official

Name: DAVID MICHAEL MELAMED
Title or Position: PRESIDENT
Credential: MD
Phone: 575-628-0926