Basic Information
| Provider Information | |||||||||
| NPI: | 1043245061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRELL | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27829 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052321920 | ||||||||
| FaxNumber: | 5057279276 | ||||||||
| Practice Location | |||||||||
| Address1: | 4705 MONTGOMERY NE | ||||||||
| Address2: | SUITE 301-302 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052546500 | ||||||||
| FaxNumber: | 5052546532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 82234 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 66206715 | 05 | NM | MEDICAID |