Healthcare Provider Details

I. General information

NPI: 1780774836
Provider Name (Legal Business Name): KAREN M VAN DE VELDE-KOSSMANN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN M VAN DE VELDE MD

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST SUITE D-2
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

2019 GALISTEO ST SUITE D-2
SANTA FE NM
87505-2143
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-5025
  • Fax:
Mailing address:
  • Phone: 505-986-5025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberNM94-413
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: