Provider Demographics
NPI:1336127836
Name:PHELPS, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:PHELPS
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:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:5901 HARPER DR NE
Practice Address - Street 2:PMG URGENT CARE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3587
Practice Address - Country:US
Practice Address - Phone:505-823-8233
Practice Address - Fax:505-823-8059
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD26058207QS0010X
NMMD2013-0032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22371061Medicaid
OR027892Medicaid
OR027892Medicaid
NM270443YMBDMedicare PIN
ORR136275Medicare PIN