Healthcare Provider Details

I. General information

NPI: 1396906798
Provider Name (Legal Business Name): UNMSOM 89
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-4905
US

IV. Provider business mailing address

1821 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-4905
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-1228
  • Fax: 505-255-1394
Mailing address:
  • Phone: 505-255-1228
  • Fax: 505-255-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03-136327-00-0
License Number StateNM

VIII. Authorized Official

Name: DONALD J ORTIZ
Title or Position: PARTNER
Credential: MD
Phone: 505-255-1228