Healthcare Provider Details

I. General information

NPI: 1508002981
Provider Name (Legal Business Name): MARY-THERESA LEVENTHAL BAKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MESA LEVENTHAL BAKER M.D.

II. Dates (important events)

Enumeration Date: 01/06/2009
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SILVER AVE SW 2ND FLOOR
ALBUQUERQUE NM
87102-3123
US

IV. Provider business mailing address

625 SILVER AVE SW 2ND FLOOR
ALBUQUERQUE NM
87102-3123
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6849
  • Fax:
Mailing address:
  • Phone: 505-272-6849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberMD2013-0585
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0039907
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: