Healthcare Provider Details

I. General information

NPI: 1396025060
Provider Name (Legal Business Name): MARIANTONIETA TIRADO GONZALEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-938-8100
  • Fax: 505-938-8868
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2019025553
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number2019025553
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number60822
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberMD2025-0726
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: