Healthcare Provider Details

I. General information

NPI: 1811935208
Provider Name (Legal Business Name): MICHAEL DANE PALESTINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 HARKLE RD STE E
SANTA FE NM
87505-4765
US

IV. Provider business mailing address

2334 WILDERNESS WAY
SANTA FE NM
87505-5945
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-8200
  • Fax: 505-989-8131
Mailing address:
  • Phone: 505-984-8610
  • Fax: 505-984-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number9996
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: