Provider Demographics
NPI:1457460776
Name:ARCHULETA, MANUEL C (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:C
Last Name:ARCHULETA
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: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:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG ISLETA
Practice Address - Street 2:3436 ISLETA BLVD SW
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105
Practice Address - Country:US
Practice Address - Phone:505-462-7777
Practice Address - Fax:505-462-7880
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74-117208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1750Medicaid
C96825Medicare UPIN
345510206Medicare PIN