Provider Demographics
NPI:1417957366
Name:ABBOTT, WILLIAM CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CHARLES
Last Name:ABBOTT
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 1:4123 MONTGOMERY BLVD. NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-7719
Mailing Address - Country:US
Mailing Address - Phone:505-884-6742
Mailing Address - Fax:505-884-6845
Practice Address - Street 1:4123 MONTGOMERY BLVD. NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-7719
Practice Address - Country:US
Practice Address - Phone:505-884-6742
Practice Address - Fax:505-884-6845
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-99208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34033Medicaid
NMC96816Medicare UPIN