Basic Information
| Provider Information | |||||||||
| NPI: | 1811935208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALESTINE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2334 WILDERNESS WAY | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875055945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059848610 | ||||||||
| FaxNumber: | 5059840127 | ||||||||
| Practice Location | |||||||||
| Address1: | 649 HARKLE RD STE E | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059898200 | ||||||||
| FaxNumber: | 5059898131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 02/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 9996 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 71946 | 05 | NM | MEDICAID |