Healthcare Provider Details

I. General information

NPI: 1255399630
Provider Name (Legal Business Name): CARLOS J ESPARZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3846 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

IV. Provider business mailing address

3846 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4479
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-1711
  • Fax: 505-242-0291
Mailing address:
  • Phone: 505-242-1711
  • Fax: 505-314-0547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number97227
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: