Healthcare Provider Details

I. General information

NPI: 1689296436
Provider Name (Legal Business Name): VANESSA ALEXANDRA HURTADO TANDAZO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

714 S BELLA VISTA ST
TAMPA FL
33609-4305
US

V. Phone/Fax

Practice location:
  • Phone: 305-301-5458
  • Fax:
Mailing address:
  • Phone: 305-301-5458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD2025-1153
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: