Provider Demographics
NPI:1386123701
Name:AWWAL, TALHA ABDUL (MD)
Entity type:Individual
Prefix:
First Name:TALHA
Middle Name:ABDUL
Last Name:AWWAL
Suffix:
Gender:M
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:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1574
Mailing Address - Country:US
Mailing Address - Phone:575-627-9500
Mailing Address - Fax:575-627-9520
Practice Address - Street 1:101 S CANAL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5713
Practice Address - Country:US
Practice Address - Phone:575-234-1466
Practice Address - Fax:575-628-1099
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2021-0612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program