Provider Demographics
NPI:1770789125
Name:KILEEN, MARTIN JON (MD,MPH)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JON
Last Name:KILEEN
Suffix:
Gender:M
Credentials:MD,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 SAGEBRUSH ST.
Mailing Address - Street 2:ISLETA HEALTH CENTER
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022
Mailing Address - Country:US
Mailing Address - Phone:505-869-4866
Mailing Address - Fax:
Practice Address - Street 1:SANTA ANA CLINIC
Practice Address - Street 2:O2-C DOVE RD
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004
Practice Address - Country:US
Practice Address - Phone:505-867-2497
Practice Address - Fax:505-867-1526
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0014207Q00000X
MT6242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty