Provider Demographics
NPI:1720159890
Name:MANSFIELD, WILLIAM T (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
Last Name:MANSFIELD
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 1:71 CAMINO CABO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-2277
Mailing Address - Country:US
Mailing Address - Phone:505-690-9545
Mailing Address - Fax:
Practice Address - Street 1:504 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2512
Practice Address - Country:US
Practice Address - Phone:505-724-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC-06-1072207R00000X
NMMD2010-0485207RC0200X, 207RC0000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM86181084Medicaid