Healthcare Provider Details

I. General information

NPI: 1558291914
Provider Name (Legal Business Name): DORTHEA DEANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9607 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-2523
US

IV. Provider business mailing address

9607 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-2523
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-4761
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number68-83
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: