Healthcare Provider Details

I. General information

NPI: 1649299942
Provider Name (Legal Business Name): GILBERTO HEREDIA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8171
  • Fax: 505-246-0684
Mailing address:
  • Phone: 505-842-8171
  • Fax: 505-246-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number98288
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: