Provider Demographics
NPI:1780617357
Name:KWIATKOWSKI, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:KWIATKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 DR MARTIN LUTHER KING JR AVE NE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3661
Mailing Address - Country:US
Mailing Address - Phone:505-262-7281
Mailing Address - Fax:505-262-7622
Practice Address - Street 1:715 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:SUITE 301
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3661
Practice Address - Country:US
Practice Address - Phone:505-262-7281
Practice Address - Fax:505-262-7622
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM200159208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME2344Medicaid
NM341430303Medicare ID - Type Unspecified
NME2344Medicaid