Provider Demographics
NPI:1174617542
Name:GIUDICE, VIVIAN B (MD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:B
Last Name:GIUDICE
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 1:801 ENCINO PL NE
Mailing Address - Street 2:STE A6
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2641
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:801 ENCINO PL NE
Practice Address - Street 2:STE A6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2641
Practice Address - Country:US
Practice Address - Phone:505-224-7400
Practice Address - Fax:505-224-7404
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM85-0367991193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193400000XGroupSingle Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26526Medicaid
341320009Medicare PIN
NM26526Medicaid