Healthcare Provider Details

I. General information

NPI: 1295069201
Provider Name (Legal Business Name): MR. ANTONIO JOSE TRUJILLO III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 LOPEZ RD SW
ALBUQUERQUE NM
87105-3954
US

IV. Provider business mailing address

1101 LOPEZ RD SW
ALBUQUERQUE NM
87105-3954
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-7060
  • Fax:
Mailing address:
  • Phone: 505-877-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: