Healthcare Provider Details

I. General information

NPI: 1710023767
Provider Name (Legal Business Name): ANGELO GUILLERMO PEZZAROSSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 ALAMEDA BLVD NW
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

PO BOX 16068
ALBUQUERQUE NM
87191-6068
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-4465
  • Fax: 505-792-8578
Mailing address:
  • Phone: 505-792-4465
  • Fax: 505-792-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberNM7581
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: