Healthcare Provider Details

I. General information

NPI: 1386665529
Provider Name (Legal Business Name): GLENROY HEYWOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE SUITE 202
ALBUQUERQUE NM
87109-4497
US

IV. Provider business mailing address

4901 LANG AVE NE SUITE 202
ALBUQUERQUE NM
87109-4497
US

V. Phone/Fax

Practice location:
  • Phone: 505-227-9737
  • Fax:
Mailing address:
  • Phone: 505-227-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2001-214
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2001-214
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: