1770789125 NPI number — DR. MARTIN JON KILEEN M.D.,M.P.H.

Table of content: DR. MARTIN JON KILEEN M.D.,M.P.H. (NPI 1770789125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770789125 NPI number — DR. MARTIN JON KILEEN M.D.,M.P.H.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILEEN
Provider First Name:
MARTIN
Provider Middle Name:
JON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.,M.P.H.
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:
1770789125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 SAGEBRUSH ST.
Provider Second Line Business Mailing Address:
ISLETA HEALTH CENTER
Provider Business Mailing Address City Name:
ISLETA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-869-4866
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SANTA ANA CLINIC
Provider Second Line Business Practice Location Address:
O2-C DOVE RD
Provider Business Practice Location Address City Name:
BERNALILLO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-867-2497
Provider Business Practice Location Address Fax Number:
505-867-1526
Provider Enumeration Date:
06/22/2007

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: 207Q00000X , with the licence number:  MD2014-0014 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 6242 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com