Basic Information
Provider Information | |||||||||
NPI: | 1932179124 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | METILDI | ||||||||
FirstName: | CARMEN | ||||||||
MiddleName: | DOROTHEA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11995 SINGLETREE LN | ||||||||
Address2: | STE 500 | ||||||||
City: | EDEN PRAIRIE | ||||||||
State: | MN | ||||||||
PostalCode: | 553445347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525951301 | ||||||||
FaxNumber: | 6122944903 | ||||||||
Practice Location | |||||||||
Address1: | 2450 S TELSHOR BLVD | ||||||||
Address2: |   | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880115069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525951100 | ||||||||
FaxNumber: | 6122944903 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 06/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 157670 | NY | N |   | Other Service Providers | Specialist |   | 2085R0202X | MD2009-0746 | NM | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.