Provider Demographics
NPI:1972549970
Name:BERDECIA, MILA (MD)
Entity Type:Individual
Prefix:
First Name:MILA
Middle Name:
Last Name:BERDECIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 DR MARTIN LUTHER KING JR AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3619
Mailing Address - Country:US
Mailing Address - Phone:505-727-5144
Mailing Address - Fax:
Practice Address - Street 1:601 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3619
Practice Address - Country:US
Practice Address - Phone:407-754-8195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD16115207Q00000X
NC9701248207Q00000X
NMMD2011-0759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1972549970Medicaid
SC161158Medicaid
NCNCM582DMedicare PIN
NC1972549970Medicaid
SC161158Medicaid
NCNCM582CMedicare PIN
NCNCM582AMedicare PIN