Provider Demographics
NPI:1770593774
Name:STUCKWISCH, DAWN (MD)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:STUCKWISCH
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 1:11601 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2660
Mailing Address - Country:US
Mailing Address - Phone:505-814-1995
Mailing Address - Fax:
Practice Address - Street 1:11601 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2660
Practice Address - Country:US
Practice Address - Phone:505-814-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054092207P00000X
NMMD2020-1061207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200341050Medicaid
IN200341050Medicaid
IN233790FMedicare ID - Type UnspecifiedMCARE #