Healthcare Provider Details

I. General information

NPI: 1043743008
Provider Name (Legal Business Name): JALEH M AKHAVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 11/14/2020
Certification Date: 11/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNMH 2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-8045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2020-0122
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: