Basic Information
| Provider Information | |||||||||
| NPI: | 1568542801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAPIA | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4420 IRVING BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276300 | ||||||||
| FaxNumber: | 5057279588 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 IRVING BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276300 | ||||||||
| FaxNumber: | 5057279588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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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 | 208000000X | MD2018-0464 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | M2485 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 36478725 | 05 | NM | MEDICAID | 179029701 | 05 | TX | MEDICAID |