Provider Demographics
NPI:1518920099
Name:CUNNANE, MARY THERESE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESE
Last Name:CUNNANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6320 RIVERSIDE PLAZA LN NW STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1710
Mailing Address - Country:US
Mailing Address - Phone:505-843-6168
Mailing Address - Fax:505-792-1978
Practice Address - Street 1:4640 JEFFERSON LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2127
Practice Address - Country:US
Practice Address - Phone:505-843-6168
Practice Address - Fax:505-792-1978
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24905207V00000X
NY147803-1207VG0400X
NM88-149207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000927695002OtherBC/BS OF WESTERN NEW YORK
NM00008169Medicaid
NYP010147803OtherBLUE CHOICE
NY5362090OtherAETNA
NY171575CKOtherPREFERRED CARE
NYP00265970OtherRAILROAD
NYP00265970OtherRAILROAD
NY5362090OtherAETNA
NYP010147803OtherBLUE CHOICE
NY000927695003OtherBC/BS OF WESTERN NEW YORK
NYD35590Medicare UPIN
NY000927695003OtherBC/BS OF WESTERN NEW YORK