Provider Demographics
NPI:1003804923
Name:KASTENDIECK, KURT D (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:D
Last Name:KASTENDIECK
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 1:421 SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-992-3334
Mailing Address - Fax:505-992-1998
Practice Address - Street 1:421 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-992-3334
Practice Address - Fax:505-992-1998
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM200152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF1927Medicaid
NMF1927Medicaid
NMH45888Medicare UPIN