Healthcare Provider Details

I. General information

NPI: 1407099559
Provider Name (Legal Business Name): SILAJA CHERUVU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2009
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 NORTH CENTRO FAMILIAR
ALBUQUERQUE NM
87105
US

IV. Provider business mailing address

1804 ANDERSON PL SE
ALBUQUERQUE NM
87108-4503
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2012-0110
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: