Healthcare Provider Details

I. General information

NPI: 1619536737
Provider Name (Legal Business Name): DAVID ARMANDO VIVAS VILLARREAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING BLVD NE
ALBUQUERQUE NM
87112-5046
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5300
  • Fax: 505-291-5302
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11107
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2022-1489
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: