Provider Demographics
NPI:1063513992
Name:MCDONNELL, ROY DALE (BCO)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:DALE
Last Name:MCDONNELL
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1102
Mailing Address - Country:US
Mailing Address - Phone:505-884-2927
Mailing Address - Fax:505-884-2672
Practice Address - Street 1:4117 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1102
Practice Address - Country:US
Practice Address - Phone:505-884-2927
Practice Address - Fax:505-884-2672
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT2326Medicaid
NM0600150001Medicare NSC