Provider Demographics
NPI:1477654697
Name:ABOUDA, MUSTAPHA KAMEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MUSTAPHA
Middle Name:KAMEL
Last Name:ABOUDA
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 2219
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2219
Mailing Address - Country:US
Mailing Address - Phone:505-753-9292
Mailing Address - Fax:505-753-1866
Practice Address - Street 1:1302 E CALLE DE MERCED
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-753-9292
Practice Address - Fax:505-753-1866
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM020550567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM202005111OtherPRESBYTERIAN
NM98800825Medicaid
NMSX159OtherLOVELACE SALUD
NM90382OtherLOVELACE COMMERCIAL
NMNM009X52OtherBCBS
NMQMYPR0070730OtherMOLINA
NMSX159OtherLOVELACE SALUD
NMQMYPR0070730OtherMOLINA
NMNM009X52OtherBCBS
NM343533200Medicare ID - Type Unspecified