Healthcare Provider Details

I. General information

NPI: 1770072001
Provider Name (Legal Business Name): KIRA MACDOUGALL MD.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date: 12/13/2018
Reactivation Date: 02/05/2019

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-3361
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD2024-0168
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: