Healthcare Provider Details

I. General information

NPI: 1417313826
Provider Name (Legal Business Name): ANTHONY WILLERT LD, RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE 5640
ALBUQUERQUE NM
87106-4920
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-6530
  • Fax: 505-563-6325
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-1043
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: