Healthcare Provider Details

I. General information

NPI: 1184962680
Provider Name (Legal Business Name): VALERIA PETKOVA ILIEVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-265-2803
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-265-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD60846867
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2015-0474
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD2016-0779
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: