Healthcare Provider Details

I. General information

NPI: 1942267596
Provider Name (Legal Business Name): MICHAEL DUDELCZYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 11/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 2ND ST STE 44B
SANTA FE NM
87505-3519
US

IV. Provider business mailing address

1807 2ND ST STE 44B SUITE 44B
SANTA FE NM
87505-3519
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-7080
  • Fax: 505-757-7080
Mailing address:
  • Phone: 505-757-7080
  • Fax: 505-757-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number7524
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: