Healthcare Provider Details

I. General information

NPI: 1326044512
Provider Name (Legal Business Name): INFECTIOUS DISEASES AND INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

IV. Provider business mailing address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

V. Phone/Fax

Practice location:
  • Phone: 505-848-3730
  • Fax: 505-848-3732
Mailing address:
  • Phone: 505-848-3730
  • Fax: 505-848-3732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number78-15
License Number StateNM

VIII. Authorized Official

Name: JANIVA BACK
Title or Position: PRACTICE MANAGER
Credential:
Phone: 505-848-3730