Healthcare Provider Details

I. General information

NPI: 1124053210
Provider Name (Legal Business Name): OPTUMCARE NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 TRANSPORT ST SE
ALBUQUERQUE NM
87106-4382
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7000
  • Fax: 505-262-7652
Mailing address:
  • Phone: 505-262-7000
  • Fax: 505-262-7652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32D0685327
License Number StateNM

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 702-480-2550