Healthcare Provider Details

I. General information

NPI: 1851390397
Provider Name (Legal Business Name): RONALD J ESCUDERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 WOLCOTT AVE NE SUITE A
ALBUQUERQUE NM
87109-4571
US

IV. Provider business mailing address

4100 WOLCOTT AVE NE SUITE A
ALBUQUERQUE NM
87109-4571
US

V. Phone/Fax

Practice location:
  • Phone: 505-855-5500
  • Fax: 505-855-5501
Mailing address:
  • Phone: 505-855-5500
  • Fax: 505-855-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number91-196
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: