Provider Demographics
NPI:1710981147
Name:STUTZMAN, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:STUTZMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4650 JEFFERSON LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2127
Mailing Address - Country:US
Mailing Address - Phone:505-727-7900
Mailing Address - Fax:505-727-7942
Practice Address - Street 1:4650 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:505-727-7900
Practice Address - Fax:505-727-7942
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-1592085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00039651Medicaid
NM300068898OtherMEDICARE RAILROAD
NM300068898OtherMEDICARE RAILROAD
NMC98130Medicare UPIN
NMRADIO105Medicare PIN
NMNM002552OtherBLUE SHIELD/NM
NM4596955OtherAETNA / PRONET
NM39651Medicaid