Healthcare Provider Details

I. General information

NPI: 1528044393
Provider Name (Legal Business Name): MICHAEL J. VENDRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

4220 HERSCHEL AVE APT 809
DALLAS TX
75219-2380
US

V. Phone/Fax

Practice location:
  • Phone: 651-245-3950
  • Fax: 413-643-4773
Mailing address:
  • Phone: 651-245-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number44127
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD00047308
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number80-278
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: