1124179486 NPI number — DONALD LEE KETTWICH M.D.

Table of content: (NPI 1538936471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124179486 NPI number — DONALD LEE KETTWICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTWICH
Provider First Name:
DONALD
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124179486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 ENCINO PL NE
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87102-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-245-5737
Provider Business Mailing Address Fax Number:
505-245-5739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 ENCINO PL NE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102-2619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-245-5737
Provider Business Practice Location Address Fax Number:
505-245-5739
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  76-208 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00015941 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85-0284119 . This is a "JOHN ALDEN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 00NM019E05 . This is a "BLUE CROSS-BLUE SHIELD-NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "TRICARE FOR LIFE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "IBEW-NECA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "GEHA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "AARP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "E.B.C." identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 201005185 . This is a "PRESBYTERIAN HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "LOVELACE HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "PRINCIPAL LIFE INS." identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "CIGNA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "UPREHS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "UNITED AMERICAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "N.M. PIPE TRADES" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 85-0284119 . This is a "AETNA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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