Basic Information
| Provider Information | |||||||||
| NPI: | 1255315057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FILLMORE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059983096 | ||||||||
| FaxNumber: | 5059983100 | ||||||||
| Practice Location | |||||||||
| Address1: | 8020 CONSTITUTION PL NE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059981317 | ||||||||
| FaxNumber: | 5059981308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | MD2008-0074 | NM | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | MD2008-0074 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000E7354 | 05 | NM | MEDICAID |