Provider Demographics
NPI:1558367888
Name:SUNDE, SCOTT T (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:T
Last Name:SUNDE
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 1:419 TULANE DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 VASSAR DRIVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2725
Practice Address - Country:US
Practice Address - Phone:505-248-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79-285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8HM190OtherMEDICARE PTAN
NMHSZ162OtherMEDICARE PART B
NMS5549Medicaid
NMK3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM05679079Medicaid
NMHSZ196OtherMEDICARE PART B
NM05679079Medicaid
NMK3526Medicaid