Healthcare Provider Details

I. General information

NPI: 1295717833
Provider Name (Legal Business Name): ALFONSO R DE LA TORRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 JEFFERSON ST NE STE 100
ALBUQUERQUE NM
87109-3486
US

IV. Provider business mailing address

6500 JEFFERSON ST NE STE 100
ALBUQUERQUE NM
87109-3486
US

V. Phone/Fax

Practice location:
  • Phone: 505-875-0103
  • Fax: 505-875-0388
Mailing address:
  • Phone: 505-875-0103
  • Fax: 505-875-0388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number75191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: