Provider Demographics
NPI:1235377268
Name:BEVERLY A. PUCKA, MD P.C.
Entity Type:Organization
Organization Name:BEVERLY A. PUCKA, MD P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PUCKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-842-8741
Mailing Address - Street 1:8120 CONSTITUTION PL NE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7654
Mailing Address - Country:US
Mailing Address - Phone:505-842-8741
Mailing Address - Fax:505-842-8190
Practice Address - Street 1:8120 CONSTITUTION PL NE
Practice Address - Street 2:SUITE 220
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7654
Practice Address - Country:US
Practice Address - Phone:505-842-8741
Practice Address - Fax:505-842-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-107207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37325Medicaid
NMC98039Medicare UPIN