Provider Demographics
NPI:1689125866
Name:MUDD, MARK R (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:MUDD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LIVINGSTON LOOP STE C2
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9753
Mailing Address - Country:US
Mailing Address - Phone:915-875-4705
Mailing Address - Fax:
Practice Address - Street 1:3850 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8288
Practice Address - Country:US
Practice Address - Phone:575-521-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2150111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor