Provider Demographics
NPI:1124281381
Name:CARDWELL, CRYSTAL D (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:D
Last Name:CARDWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 LAS LOMAS RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2633
Mailing Address - Country:US
Mailing Address - Phone:505-924-2650
Mailing Address - Fax:800-974-1595
Practice Address - Street 1:904 LAS LOMAS RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2633
Practice Address - Country:US
Practice Address - Phone:505-924-2650
Practice Address - Fax:800-974-1595
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0030207Q00000X
ND12122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85222364Medicaid
NM85222364Medicaid