Healthcare Provider Details

I. General information

NPI: 1659304210
Provider Name (Legal Business Name): AJIT S TIPIRNENI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

PO BOX 27829
ALBUQUERQUE NM
87125
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7905
  • Fax: 505-262-7217
Mailing address:
  • Phone: 505-232-1920
  • Fax: 505-727-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number20020240
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: