Healthcare Provider Details

I. General information

NPI: 1053536813
Provider Name (Legal Business Name): JURGEN H UPPLEGGER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4233 MONTGOMERY BLVD NE STE 140W
ALBUQUERQUE NM
87109-6707
US

IV. Provider business mailing address

4233 MONTGOMERY BLVD NE STE 140W
ALBUQUERQUE NM
87109-6707
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-9570
  • Fax: 505-883-4163
Mailing address:
  • Phone: 505-883-9570
  • Fax: 505-883-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number74-256
License Number StateNM

VIII. Authorized Official

Name: JURGEN HEINZ UPPLEGGER
Title or Position: PRESIDENT
Credential: MD
Phone: 505-883-9570