Healthcare Provider Details

I. General information

NPI: 1043279904
Provider Name (Legal Business Name): LUIS CENTENERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 THE 25 WAY NE SUITE 150
ALBUQUERQUE NM
87109-5857
US

IV. Provider business mailing address

4411 THE 25 WAY NE SUITE 150
ALBUQUERQUE NM
87109-5857
US

V. Phone/Fax

Practice location:
  • Phone: 505-332-5800
  • Fax: 505-332-6919
Mailing address:
  • Phone: 505-332-5800
  • Fax: 505-332-6921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2001-152
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2001-152
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: