Basic Information
| Provider Information | |||||||||
| NPI: | 1336175355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | SUITE 6600 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | SUITE 6600 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/25/2013 | ||||||||
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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 | 207XX0005X | 2003-0525 | NM | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 48425362 | 05 | NM | MEDICAID |