Provider Demographics
NPI:1487677571
Name:DEPREST, MICHAEL H (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:DEPREST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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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:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG URGENT CARE
Practice Address - Street 2:5901 HARPER DRIVE NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-823-8519
Practice Address - Fax:505-823-8355
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM93-36207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3388Medicaid
E65302Medicare UPIN
NM3388Medicaid