Healthcare Provider Details

I. General information

NPI: 1982961066
Provider Name (Legal Business Name): ATHANASIOS DESALERMOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 MONTGOMERY BLVD NE STE 201
ALBUQUERQUE NM
87109-1233
US

IV. Provider business mailing address

PO BOX 3160
ANDOVER MA
01810-0803
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7833
  • Fax:
Mailing address:
  • Phone: 978-474-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2025041095
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number274317
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: