Healthcare Provider Details

I. General information

NPI: 1740672971
Provider Name (Legal Business Name): MARILYN L MATTHEWS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 HARKLE RD SUITE B
SANTA FE NM
87505-4784
US

IV. Provider business mailing address

3115 SIRINGO RD
SANTA FE NM
87507-5085
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-9134
  • Fax:
Mailing address:
  • Phone: 505-660-9134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number86-87
License Number StateNM

VIII. Authorized Official

Name: DR. MARILYN L MATTHEWS
Title or Position: CEO
Credential: MD
Phone: 505-660-9134