Provider Demographics
NPI:1053327361
Name:STOLLER, CLIFFORD R (MD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:R
Last Name:STOLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 SEAGULL ST NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2500
Mailing Address - Country:US
Mailing Address - Phone:505-883-4395
Mailing Address - Fax:505-883-4397
Practice Address - Street 1:6100 SEAGULL ST NE
Practice Address - Street 2:SUITE 106
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2500
Practice Address - Country:US
Practice Address - Phone:505-883-4395
Practice Address - Fax:505-883-4397
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-3162081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000037341Medicaid
NM000037341Medicaid