Provider Demographics
NPI:1215997358
Name:MADRID, M EILEEN (MD)
Entity type:Individual
Prefix:
First Name:M
Middle Name:EILEEN
Last Name:MADRID
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 1:419 MANZANARES ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-3882
Mailing Address - Country:US
Mailing Address - Phone:505-425-6773
Mailing Address - Fax:505-426-9238
Practice Address - Street 1:419 MANZANARES ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3882
Practice Address - Country:US
Practice Address - Phone:505-425-6773
Practice Address - Fax:505-426-9238
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-79174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00007088Medicaid
NM2-13277-2Medicare ID - Type Unspecified
NM00007088Medicaid