Healthcare Provider Details

I. General information

NPI: 1174622393
Provider Name (Legal Business Name): CLEVELAND HENDRICK PARDUE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 ST MICHAELS DRIVE SUITE 202
SANTA FE NM
87505
US

IV. Provider business mailing address

455 SAINT MICHAELS DR PHYSICIAN PRACTICES/CENTRAL BILLING OFFICE
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-0303
  • Fax: 505-984-1116
Mailing address:
  • Phone: 505-820-5227
  • Fax: 505-820-5645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number82101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: