Basic Information
| Provider Information | |||||||||
| NPI: | 1174622393 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARDUE | ||||||||
| FirstName: | CLEVELAND | ||||||||
| MiddleName: | HENDRICK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | PHYSICIAN PRACTICES/CENTRAL BILLING OFFICE | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058205227 | ||||||||
| FaxNumber: | 5058205645 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 ST MICHAELS DRIVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059840303 | ||||||||
| FaxNumber: | 5059841116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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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 | 207VG0400X | 82101 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 20404 | 05 | NM | MEDICAID |