Provider Demographics
NPI:1922018712
Name:CARMODY, PHILLIP WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WILLIAM
Last Name:CARMODY
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 1:8906 BROCK LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-3753
Mailing Address - Country:US
Mailing Address - Phone:505-858-0716
Mailing Address - Fax:
Practice Address - Street 1:10400 ACADEMY RD NE
Practice Address - Street 2:#230
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1229
Practice Address - Country:US
Practice Address - Phone:505-298-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00007823Medicaid
NM00007823Medicaid