Provider Demographics
NPI:1255315057
Name:FILLMORE, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8020 CONSTITUTION PL NE
Mailing Address - Street 2:STE 202
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7640
Mailing Address - Country:US
Mailing Address - Phone:505-998-3096
Mailing Address - Fax:505-998-3100
Practice Address - Street 1:8020 CONSTITUTION PL NE
Practice Address - Street 2:STE 101
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7640
Practice Address - Country:US
Practice Address - Phone:505-998-1317
Practice Address - Fax:505-998-1308
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2008-00742085R0204X, 2085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000E7354Medicaid
ORP00058651OtherRR MC
NM000E7354Medicaid
OR287603Medicaid
WA8277865Medicaid
WA8277865Medicaid
ORP00058651OtherRR MC
NMNM300191Medicare PIN