Healthcare Provider Details

I. General information

NPI: 1437395332
Provider Name (Legal Business Name): HIGH DESERT PEDICATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8650 ALMEDA BOULEVARD, NE UNIT 101 E
ALBUQUERQUE NM
87122
US

IV. Provider business mailing address

8650 ALMEDA BOULEVARD, NE UNIT 101 E
ALBUQUERQUE NM
87122
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-1866
  • Fax: 505-255-1852
Mailing address:
  • Phone: 505-255-1866
  • Fax: 505-255-1852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: IBUKI SUGA
Title or Position: OWNER/ADMINISTRATOR
Credential: MD
Phone: 505-255-1866