Provider Demographics
NPI:1184690364
Name:DEAN, JACQUELINE KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:KIM
Last Name:DEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1617 UNIVERSITY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1710
Mailing Address - Country:US
Mailing Address - Phone:505-341-4841
Mailing Address - Fax:505-345-9914
Practice Address - Street 1:1617 UNIVERSITY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1710
Practice Address - Country:US
Practice Address - Phone:505-341-4841
Practice Address - Fax:505-345-9914
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM2001-170207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12737011Medicaid
G10710Medicare UPIN